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THE 



DUBLIN JOURNAL 



OP 



MEDICAL SCIENCE; 



KXBIBITIMG 



A C O M P«qf>H BT* Sry^E VIEW 




lES 



IN 



MEDICINE, SCROERY, AND THE COLLATERAL 

SCIENCES. 



VOL. XII. 



DUBLIN: 

PUBLISHED BY HODGES AND SMITH, 

21, collkgb-gbbxh; 

LONGMAN. RE£S,& CO. ^nd SIMPKIN,MABSHALL,&C0.L0ND0N; 

MACLACHLAN AND STEWART, EDINBURGH ; ano 

SMITH AND SON, GLASGOW. 

1838. 




Printed by R. Graisberbt. 




NAL 



MEDICAL SCIENCE, 

1 SEPTEMBER, 1837. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. I. — Observations on Bruit de SovffleU By David C. 
Naole, A. B., M. B., one of the Physicians to the Dublin 
General Dispensary. 

" Every raan/' said the good and philosophic Johnson, '' from 
the highest to the lowest oonditton, ought to warm his heart and 
animate his endeavours with the hopes of being useful to the 
world by advancing the art which it is his lot to exercise." 
This principle, thus so nobly inculcated, seems so much to in- 
floenee the zeal of some distinguished physicians, by whom 
this — the metropolis of my native country — is, at present, so 
brilliantly ornamented, ^t one is led to expect from it, if well 
directed, results the most beneficial to the interests of medical 
science. And I feel ttiat those interests will not be compro* 
niised by an attempt to check this laudable spirit of inquiry, 
whenever it becomes either too rapid in its career, or likely to 
deviate too much into the regions of fancy. 

Influenced by feelings of this description, I hope it will not 
be unproductive of advantage to direct attention to a paper on 

VOL. XII. MO. 34. B 



2 Dr. Nagle on Bruit de Sovfflet. 

^^ the Mechanism of Bruit de SoufiSet," which appeared in the 
number of this Journal for November last. It will, at leasts be 
excusable, as in a paper, published in the Lancet for May 28th, 
1831, in opposition to the doctrine then recently propounded, 
regarding the '^ motions and sounds of the heart," I expressed 
myself to the following eflfect : — ^' I confess I cannot possibly 
bring myself to subscribe to the doctrine of those, who would 
persuade themselves and others, that bruit de soufflet is owing 
to the passage of the blood through a narrow opening into a 
wider cavity, and detected only in the latter." Independently 
of some facts there adduced in support of my opinion, I added, 
^* besides their principle will not account for the soufflet heard 
during pregnancy." The author of the theory having lately 
more fully developed his ideas on the mechanism of bruit de 
soufflet, and having adduced this uterine murmur in support of 
his views, it may not be useless to discuss the question ; and 
consider whether bis doctrine is, as he imagines, sufficient to 
account for the phenomenon ^' under all the apparently contra- 
dictory circumstances in which it is found to occur," 

•' The two conditions," says the author, " which constitute 
the mechanism of bruit de soufflet are; 1st, a current-like mo- 
tion of the blood, tending to produce vibrations in the sides of 
the cavities or arteries tbrou^ which it is moving ; and 2ndly, 
a diminished tension of the parietes themselves, in consequence 
of which these pacietea are easily thrown into vibrations by the 
irregular currents of the contained fluids which vibrations cause, 
on the sense of touch, fremissement, and on the sense of hear- 
ing, bruit de soufflet." In the middle of his paper he says, 
'' We now come to one of the most singular instances of bruit 
de soufflet, that heard in the pregnant state ;" and, from a -work 
not long since published on obstetric auscultation, adduces tlie 
following extract to bear him out in his views. ** The placentar 
portion appears to consist of a congeries of vessels, tortuous, 
ramifying, and expanding into cells or sinuses, while the re- 
maining part exhibits the parenchymatous structure of this 



Dr. Nagle on Bruit de Soufflet. 3 

organ, with merely occasional vessels interposed." ** There is 
therefore," he goes on to reason, *' especially in the placentar 
portion of the ateros, a stream of blood rushing from one or two 
arteries into an extensive system of enlarged tubes. After each 
contraction of the heart, the pressure of the contents of the ute- 
rus from within, and the counteracting pressure of the abdomi- 
nal muscles from without, empty in some degree, or render 
flaccid the enlarged and tortuous arteries, either by pressing 
forward into the sinuses the blood which had just been driven 
into the arteries, or by throwing back a portion of it towards? the 
main trunks, or probably by both. The tortuous arteries of the 
placentar portion of the uterus, so much enlarged, compared 
with the trunk that supplies them, are in the intervals between 
the contractions of the heart, thus brought to the first condition 
necessary to the mechanism of this sound, and in this state 
receive into them the next dash of blood from the supply 
trunks, and this fresh portion of blood, propelled onwards, runs 
along in so many rushing currents through the tortuous arteries, 
throwing the sides of those vessels into corresponding vibrations, 
and thus giving to the ear bruit de soufiSet" ! 

By the above extract, with which, as weU as Iris reiisoning 
on it, I would chiefly deal at present, it will appear the author 
assumes that the uterine murmur is seated in that part of th^ 
uterus to which the placenta is attached. I have elsewhere** 
endeavoured to show that the murmur is not necessarily seated 
in that part of the uterus ; and until I find my views overturned 
by more judicious, legitimate, and convincing arguments, than 
are contained in the work from which he derives his opinion, I 
shall not be induced to relinquish mine. The site of the mur» 
mur is a point to which I would request particular attentioti, as 
being very important in the present discussion. Now, if the 
site of the uterine murmur be in that part of the uterus to which 
the placenta is atteched, every intelligent and reasoning physi- 



See Lancet, Dec. 18th, 1830, p. 395, H teq, 



4 Dr. Nagle on Bruit de Soufflet. 

cian will concede that the seat of the murmur should vary with 
the varying situation of the placenta ; and we are all aware that 
the latter is liable to be attached to the uterus anteriorly or 
posteriorly; laterally^ or over the os uteri; but every man of 
experience and accuracy of observation will allow that the mur- 
mur> when it at all exists, is invaric^ly heard in the latercd 
parts of the uterus along the course of the lateral uterine arte- 
ries ; and it is there, and no where else, that we should look for 
it in our examinations. Supposing the placenta to be attached 
over the os uteri, where should the murmur then be most au- 
dibly heard ? Unquestionably over the pubes. Can such a fact 
be found ? I think it cannot. After the most anxious attention 
to this question, I never yet could discover the principal site of 
the murmur in any other part of the abdomen than the lateral 
regions, as I have already described.* And, indeed, by ma- 
nual examination, I have found the placenta to be attached to 
the upper part of the fundus of the uterus, while the murmur 
was heard in the usual situation. I therefore feel myself justi- 
fied in denying the supposition, that the uterine souffle is seated 
in the arteries running through the placenta ; and consequently, 
that its mechanism in the uterus at least depends on the cause 
assigned. But let me, for argument sake, grant that the 
souffle is situated in these arteries : how then could we, accord- 
ing to the theory of ** vibration and current-like motion," satis- 
factorily account for the astonishingly increased loudness which 
the souffle occasionally exhibits ; or for the vast and interesting 
variety in the qtudity of the murmur, which an acute and prac- 
tised ear will, at times, easily detect during the state of preg- 
nancy. From the spungy nature of the placenta, we know that 
it must necessarily be a bad conductor of sound ; and, conse- 
quently, that there cannot be any very exaggerated augmenta- 
tion of the sounds produced by vibration, as there is in hepati- 
zation of the lung for instance : and if any one be so fanciful as 

• See Lancet, Dec. 18lh, 1830, p. 396-7. 



Dr. Nagle on Bruit de SouffieL 5 

to imagine that vibration in the arteries of the placenta — par- 
ticularly when the circulation is rather languid — could^ by pos- 
sibility^ produce the loud sound we often detect there> I may 
much admire such a rare endowment, however unwilling I may 
feel to be possessed of it. But let us analyze the above 
extract. 

Pressure from within or without, I would respectfully sub- 
mit, has nothing to do with the production of the murmur in 
question. How do I show it ? Let the patient be turned on 
either side, and the only pressure which can be made — that by 
the foetus or liquor amnii — on the opposite one be thus lessened 
by gravitation, and let the abdominal muscles at the same time 
be relaxed ; still we have the bruit de soufBet in all its intensity. 
Will any one deny this position ? — The conclusion is inevitable. 
But let us suppose that pressure from within and without does 
empty the vessels running through the placenta in the manner 
described by the author ; and let us pay some attention to the 
inferences he draws from such a supposition, and to his mode of 
reasoning on it, and we shall find it, I apprehend, rather weak, 
inconclusive, and inconsistent. " After each contraction of the 
heart,** says the author, " the pressure of the contents of the 
uterus from within, and the counteracting pressure of the ab- 
dominal muscles from without, empty in some degree, or render 
flaccid, the enlarged or tortuous arteries" ! I If the pressure, 
thus imagined, be so great as to empty the vessels in the man- 
ner described, it follows, as a necessary consequence, that these 
arteries, kept so compact, so wedged between the compressing 
forces from within and without, cannot, by any possibility, be 
thrown into the vibrations, which the author deems requisite 
for the production of the sound in question, until that pressure 
is removed, and the vessels allowed their full play. And I 
cannot conceive by what magic it is he fancies the compressing 
force to be laid on during the intervals only between each 
contraction of the heart, and then to be so accommodatingly re- 
moved at the very moment of contraction, for the admission of 



6 Dr. Nagle on Bruit de SouffleL 

'^ a fresh dash of blood." One would suppose that the author 
was arguing in favour of the generally received doctrine regard^ 
ing the cause of bruit de soufflet, by thus opposing to the 
blood's free transmission a barrier^ which must be burst through 
by the '^ next dash from the supply trunks/' before we can have 
the vessels in his fancied mechanical condition. 

If this ad absurdum argument be not suflScient to point out 
the fallacious nature of his reasoning, let me request attention 
to the following incontrovertible fact^ and the inferences which 
naturally flow from it The uterine murmur is frequently per- 
fectly contimwus,* This cannot be denied. Let me then put 
it to the dispassionate judgment and candour of the author^ 
whether be really thinks such a phenomenon possible, if his 
reasoning be correct. His position is : that the vessels in which 
he supposes the souffle to exist, must have the power of vibra- 
tion — must be in a comparatively flaccid state to receive the 
'^ next dash of blood ;" and yet he states that they must be, 
during the intervals between the heart's contractions, so com- 
pressed^ as to '' force forward into the sinuses the blood driven 
into them, or throw back a portion of it towards the main 
trunks" ! By such reasoning it appears — to say nothing of the 
many other incongruities which it involves — that the vessels 
must be, at the same moment, wedged between two compress- 
ing forces, and yet so flaccid, as easily to admit into them the 
'* fresh dash of blood from the supply trunks." Thus he evi- 
dently assumes that the murmur cannot hecontintious; that is, 
does not occasionally exist during the whole interval between 
the heart's contractions. This would indeed be a great mistake ; 
and a little more practical acquaintance with the murmur will 
ei^ly disabuse the intelligent author of such an erroneous opi- 
nion> and induce him to exert his praiseworthy zeal for the at- 
tainment of a theory of the phenomenon in question more piro« 
bable, more likely to meet with the assent of the judicious and 



* See Lancet, Jan. 8th, 1831, p. 800. 



Mr. Radford on Inversion of the Uterus. 7 

reflecting portion of the profession. It is a principle in dia- 
lectics, as well as in the art of war, to secure for one's self a safe 
basis for operations. But I greatly apprehend that the author 
has deviated from such a principle, by taking, as the basis of his 
reasoning on this point, the statements of a gentleman, who has, 
I fear, unfortunately involved himself too deeply in a wilderness 
of contradiction, to be prudently produced as a safe guide for 
determining the true site of the uterine bruit de soufflet. 

Thus have I endeavoured to show the inconcluslveness of 
the author's reasoning, by, — 1st, the unvarying situation of the 
uterine souffle; 2nd, its intensity, and, frequently, continuous 
nature; 3rd, the utter impossibility of internal and external 
pressure being the cause of it; 4th, the evident inconsecutive- 
ness, if you will allow roe, of the reasoning on even such a sup- 
position; 5th, the vacillating and self-contradictory- statements 
of the gentleman from whose work an extract has been pro- 
duced to establish the site of the murmur. And I am un- 
avoidably forced into the conviction that the author has riot 
been happy in adducing the uterine souffle in sustainment of 
his views on the mechanism of the bellows* sound. Is he more 
successful in his reasoning on its mechanism, as applied to the 
arterial system generally ? That shall be the subject of a sub- 
sequent paper; and in treating of it — whilst I am ready to ad- 
mit the utility of theoretical reasoning, if legitimately con- 
ducted — I at least shall keep before my view, what I am 
deeply persuaded of, that refined speculation too oHen becomes, 
like the '* dream of the sleeper," a false and empty dream. 



Art. II. — Cases of Inversion oft/ie Uterus, with Retnaris. 
By Thomas Radford, Surgeon Extraordinary to the Man- 
chester Lying-in Hospital, &c,, and Lecturer on Midwifery 
at the Royal Sdiool of Medicine and Surgery. 

Inversion of the uterus differs in degree, and the terms partial 
and complete have been applied to characterize them. In par- 



\ 



8 Mr. Radford on Inversion of the Uterus. 

tial inversion the fundus may be more or less depressed, from a 
slight dimpling, to a protrusion through the os uteri into the 
vagina, or through the os externum. Under this division the 
writer classes all cases where any portion of the cervix remains 
uninflected above the os uteri, however short the angle of in- 
flection may be. In complete inversion the cervix is not in- 
flected upon itself, or embraced by the os uteri ; but this orifice 
is effaced, and the vagina is inverted to a greater or less extent, 
the fundus projecting beyond the os externum very consi- 
derably. 

Inversion has been denominated active or passive, more 
perhaps from the lapse of time, than from the particular condi- 
tion of the organ. The writer suggests, for the consideration of 
the profession, whether the words reducible and irreducible 
are not more proper. This accident may be called reducible, 
however long it has existed, provided the practitioner can by 
any safe means accomplish its replacement; and irreducible 
when every effort has been made, but unsuccessfully. By 
adopting this nomenclature the practitioner is imperatively 
called upon to exercise fully the powers of his art, before he 
can classify the disease. 

It is happily one of those misfortunes which does not so very 
often take place; although the writer is inclined to think much 
more frequently than is usually admitted.* The reason of this 
concealment is clear, if it is considered what opinion is enter- 
tained of the practitioner who has been so unfortunate as to 
meet with such an event ; there is no occurrence which throws 
more odium upon him, although generally very undeserved. 
This feeling paralyzes the energies of the surgeon, and conceal- 
ment is adopted to shield himself from this unjust imputation. 



* Dr. King it of the fame opinion. Mr. Mackenzie found two or three in- 
stances in subjects brought into the dissecting-room. Mr. Windsor, Med. Cbir. 
Trans, vol. ii. Doctor Rarosbotham, Practical Observations, Part I. page 
137. 



Mr. Radford on Inversion of the Uterus. 9 

Most writers ascribe the accident to rude pulling at the, 
funis, and to riolence in removing the placenta. This opinion, 
as wdl as others connected with this subject, equally important, 
will be round to be erroneous, if published cases are carefully 
investigated. The nature of this accident is extremely alarm- 
ing ; the patient either dies suddenly if it is not replaced, or 
gradually sinks, afler a life of protracted misery, by the irrita- 
tion and profuse mucous, purulent, and sanguineous discharge 
which takes place. The irreducible inverted uterus has been 
removed six times in the course of a few years in Great Bri- 
tain ; but the opinion of the writer is, that the operation of ex- 
tirpation, sometimes fatal, always dangerous, and which does not 
in every instance relieve the patient from those discharges which 
induced her to submit to it, will become altogether unnecessary 
if early, judicious, and persevering attempts be mdde to reduce 
it. Great odium is deserved by the practitioner who allows a 
reducible inversion to pass on to the irreducible state. 

The great fatality which occurred in the cases detailed by 
the eariy writers upon this subject, was doubtless owing to the 
obstetric practit^e being in the hands of ignorant females : the 
inverted organ was frequently mistaken for the head of a second 
child, or for some preternatural tumour which ought to be re- 
moved, and in consequence great mechanical violence was used, 
and the constitutional powers greatly exhausted before a sur- 
geon was called upon. In the present day the result is, or 
ought to be, different ; the tumour may be easily reduced, and 
the result is generally successful. 

Frotn the number of cases detailed, inferences, in a great 
measure correct, may be drawn of the nature of the causes 
which hate produced it, and also of the circumstances which 
attend it But notwithstanding the great advantages arising 
from this source, we find practitioners resting satisfied by 
merely repassing the tumour through the os externum into the 
vagina ; by which those miseries already alluded to are en- 

VOL. XII. NO. 34. c 



I 



10 Mr. Radford on Inversion of the Uterus. 

tailed upon the unhappy patient, or else her life is the for- 
feiture, and the grave conceals his ignorance.* 

Systematic writers in general adopt the opinion entertained 
by their predecessors of the circumstances which occur at the 
time of tlie inversion, more from respect to authority, than an 
accurate analysis of the cases which have been published. But 
in some material points of practice a great difference in opinion 
is to be found. 

Case I. — Mr. Wood, my late partner and respected relative, 
was requested to visit a poor woman who was delivered by a 
midwife about two hours previously. He found the patient very 
much exhausted, with pallid countenance, and a cold surface. 
Upon a vaginal examination he found a large tumour, with the pla- 
centa attached, and which he at once recognized as the utertis 
inverted. There was no hemorrhage or convulsion ; the (unis 
was of the ordinary length, and was not entwined round any 
part of the child. The midwife assured him that she had made 
no effort to remove the placenta, nor could she attribute the 
occurrence to any treatment she had adopted. Mr. Wood de- 
tached the placenta, and then reduced the uterus, which he ac- 
complished without any great diflSculty. The patient went on 
well, and recovered without any further inconvenience, except 
that of a longer confinement. 

Case II. — The writer is indebted for the following case to 
his respected friend Mr. Mann, a truly intelligent practitioner. 

^' The subject of this accident was Mrs. Birch of Great 
Bridgewater-street, a well formed, healthy young womi^, and 
this was her third confinement I was summoned to her on the 
17th day of May, 1826, about three o'clock in the aflemoon. 
I found her walking about the room, with the pains bearing 
down, and effective. In a short while after my arrival, whilst 
leaning forward on the bed, she was delivered of a fine healthy 



* See Case 24. Dr. Ramsbotham's Practical Observatiout. Glasgow Journal, 
vol. i. p. 171. 



Mr. RadFord on Inversion of the Uterus. 1 1 

male child ; from this position (as soon as the child was sepa- 
rated) she was removed carefully into the bed ; in less than ten 
minutes she had a slight pain or two. My patient expressed 
some fears lest the placenta * should sticky but on my making 
an examination per vaginam, I distinctly felt the insertion of 
the funis into the placenta^ and relieved my patient of her fears 
as to its being retained unduly. I had scarcely assured her all 
was likely to terminate well, when she was suddenly seized 
with a violent bearing down pain ; and on making a further in- 
vestigation I discovered, what I took for the instant to be the 
placenta pushed forward by a second child's head ; but having 
recourse to ocular investigation, I was soon undeceived in this 
respect, and found the uterus inverted, which had passed ex- 
ternally from the vagina, with the placenta attached to it. I 
felt very much alarmed for the fate of my patient. I first peeled 
the placenta from the fundus uteri, and then grasping the ex- 
truded part with my hand, I did not find it very difficult to re- 
introduce it into the vagina, and carry it through the os uterL 
I followed with my hand, or rather pushed it forwards, when I 
observed it suddenly start from me as a piece of Indian rubber 
would. By a subsequent examination I found all the parts in 
situ* I was now called by the nurse to examine the state of my 
patient, which indeed was very alarming ; her face became sud- 
denly pale, and bedewed with cold sweat ; her pulse was rapid 
and unsteady ; there was great prostration of strength, and a 
threatening of convulsions and death. Brandy and laudanum 
were immediately administered in free doses ; hot flannels and 
friction were applied to the extremities, &c. ; but it was more 
than two hours before I could consider my patient safe. She 
afterwards did well, and has since borne children. 

" The above is the only case which has ever occurred in my 
practice, and 1 would remark,y£r«^/y, that this inversion was en- 
tirely spontaneous, as I had not even taken hold of the funis at 
the time it happened. I mention this fact, because it was for- 
merly considered that inversion was occasioned by pulling at 



12 Mr. Radford on Inversion of the Uierm. 

the funis ' as you would at a bell-rope.' Secondly, as there 
was no bemorrhage, and as the reinversion was effected in a few 
seconds, it is somewhat difficult, in my mind, to account for the 
sudden depression of the vital powers, amounting neariy to dis^ 
solution.'' 

Case III. — Mrs. Capper, midwife, requested me to visit 
Mary Wilson, Mount-street, Knot MilU who had been delivered 
forty-eight hours. I was informed her labour was pfopiticMis; 
that the placenta was naturally detached and expelled. There 
was no hemorrhage afterwards, nor indeed any other symptom 
which required further assistance. She was induced to send 
for me at this time, because the patient had discovered some* 
thing protruding from the os externum, and which she, upon a 
first examination, considered to be a coagidum contained within 
the membranes. She applied a slight force, but it gave the 
patient great pain, and not succeeding in bringing it away, ab* 
stained from ftirther violence. When I made a vaginal exami* 
nation, I found a tumour of considerable size passing partly 
through the os externum ; it was hard and r^istant ; externally 
it felt flaky ; it was broader below than above. It was with 
great difficulty I could reach the os uteri, which tfghtly em- 
braced the upper part of the tumour. The lochial discharge 
was greater than usual, and more sanguineous. 

Altliough the case was somewhat obscured by nothing 
having o<:curred immediately after the labour, yet I was con* 
vinced, from a very careful investigation, that it was one of par* 
tial inversion ; I therefore determined to make every effort to 
replace it. My exertions were continued for two hours, and 
only given up on account of the pain produced, and the ^c* 
hausted state of the poor woman. Further attempts I oonsi* 
dered would be dangerous. From this time her health de- 
clined. Her first symptoms were those of peritoneal inflamma- 
tion, retention of urine, &c. ITie antiphlogistic plan was 
adopted, as general and local bleeding, fomentations, tur* 
pentine lotion, febrif\ige medicines, &c. When the inflam- 



Mr. Radford on Jnversion of the Uterus. 13 

matory excitement was sabdued^ I again attempted to reduce 
tbe ttunottf*, but was again unsuccessful. Her health 4e» 
dined. She now aafitered irom sanguineous, mucous, and punj^ 
lent discharge from the vagina, whkb produced great debility^ 
diarrhssa, apdiou» afieetions of tbe mouthy &c. These symp^ 
ioms QQotinued to harass her for six months, during i^hicb 
period I had in view the operation of extiipatton as so<mi as 
ei«eumstanoes would warrant its adoption. I Aequently ami-* 
mined per wofpnam^ and found the uterus gradually kssimj 
until it acquired the sice of a large pear. Duriog the whole 
progress of the case the os uteri very tightly girt the ueck of the 
tumour. The disdiarge was now more decidedly purulent 
Slie now left town for about a month, aad upon her return I 
again visited her. Her general health was improved; the va- 
ginal discharge lessened, but atill purulent. I made a vaginal 
^lamination, hut could detect no tumour. I felt the remams of 
the OS uteri, but no regular aperture ; the upper part of the va- 
gina formed a complete cul de sac. I inquired if she had dis- 
covered any substance pas»ng from the vagina ; she said she 
had Grit something pass aw^y, but thought it was ^^ a lump of 
blood.'' Her general health gradually improved, and she lived 
several years. &e died of cholera ; and I regret much I was 
not apprised of her death until some moaths afterwards. 

The case is truly interesting ; it shows what resources Na- 
tave has in her own power. It justifies the operation of extirpa- 
tioii when, as in the present ease, that period^ so precious, has 
been passed by, when reduction can be effected^ It may be 
thought that a spontaneous reinversion tcok place, as happened 
in the casos rdated by M. Delabarre and the justly celebrated 
Baudelocque.* The writer does not think it possible for this 
spontaneous change to occur, notwidistanding tbe ingenious ex- 
planation of M. DaiUiez.t 



* Gardien Traite Complet D*Accouchemens, &c. Tome iii. p. 318419. 
t DisierUtion sur le Renveriemeot. 



14 Mr. Radford on Inversion of the Uterus, 

The OS uteri acted here as a ligature, and induced the pro^ 
cess of ulcerative absorption, by which the part was separated. 
The writer made every justifiable attempt to reduce the part/ 
but has since thought that something further should have been 
tried, as he has been lately consulted in a case which was re- 
duced on the seventh day after labour.* But a material diffe- 
rence existed in the two cases; in the one the os uteri was 
atonic ; in the subject of the present history, it was rigidly con- 
stricting the cervix ; and in such cases an incision made on each 
side of the os uteri would, in the writer's opinion, add to the 
chance of reduction. Millot has advised this incision in cases 
more advanced.f Nauche also advocates the same procedure4 
Would the tobacco enema aid us in our attempt at reduction ? 

Case IV. — I was requested by the late Mr. Dick to visit a 
patient who was in labour of her first child. The pains com- 
menced at bed time the night before. The liq. amnii was dis- 
charged twelve hours before my visit, and I learned that the os 
uteri was then dilated to nearly the diameter of a crown piece. 
After the discharge of the water the pains became more feeble^ 
especially when the patient was recumbent, but when she 
changed her position to walk or sit, they increased in power ; 
on this account the patient was placed upon the lap of a female 
friend, and was delivered in this posture. After the child had 
freely cried, and the placento-foetal pulsation had ceased, the 
funis was divided ; it was of ordinary length, and did not en- 
circle the neck. The patient was now put in bed, and I placed 
my hand upon the abdomen, and found the uterus hard, and 
rather larger than is usual. I now took the funis in the left 
hand, and gently stretched it, and passed the finger of the right 
into the vagina {o examine for the placenta, but was not able to 
feel it. Whilst I made the inquiry, Mr. Dick placed his hand 

• Vide Case VI. 

t Supplement a touf les Tnit«s, &c. Tome ii. p. 262. 
% Dc« Maladies propres auz Femmev, premiere Partie, p. 14 1. Boivin et Duges 
Traits Pratique des Maladies de T Uterus. 



Mr. Radford on Inversion of the Uterus. 15 

rather suddenly upon the belly, a strong forcing pain came on, 
and the woman exclaimed^ '^ Oh ! the after-birth is coming !" 
The placenta was now found to be rapidly advancing^ and in a 
moment it passed through the os externum. I then discovered 
it was not the placenta alone^ but this mass adherent to the 
uterus, constituting an extreme degree of partial inversion. The 
protrusion was sudden and forcible, and was attended by a 
bearing down effort. The tumour was about the size of a 
child's head, hard and firm, but smooth, being covered by the 
membranes. The placenta adhered to the fundus ; little dis- 
charge took place, but the patient complained of being faint 
1 now detached the placenta, and easily accomplished it. I 
then compressed the uterus between the hands, and felt it to 
diminish in bulk. It was now passed through the os externum, 
and easily carried up, until the vagina was made tense. Resis- 
tance was now found to its further progress, but keeping a 
steady bearing upon it for some time, it gradually gave way, 
and persevering, it was passed through the os uteri. The hand 
was carried into the uterine cavity, and retained until contraction 
took place. The os uteri grasped the wrist, assuring me that 
regular action was in operation. The patient recovered without 
any interruption. She was desired to keep the recumbent po- 
sition longer than is usual, and to pay great attention to the 
bowels. 

In an attempt to reduce an extreme degree of partial inver- 
sion, it will be found that the tumour will freely pass through 
the OS externum, and as only one hand can be admitted into the 
vagina, the chief compression should be effected whilst it lies 
externally. And as the upper part of the vagina descends 
along with the uterus, no real effect can be produced until it is 
made tense by carrying this organ upwards. When it arrives 
at this point, resistance is met with, but by keeping a steady 
pressure upwards, the inflected portion of the cervix then yields, 
and it gradually recedes, followed by the hand of the operator, 
until the reduction is completed. If, instead of the plan now 



16 Mr. Radrord on Inversion of the Uterus. 

recommended) a forcible and quick attempt be mfide, the vagina 
may be separated from the uteras, and a fatal injury inflicted. 

Cask V. — Mrs. Jeal, midwifei desired me to visit Mrs. 
— , Union-street, Ancoats, who was in labour of her fourth 
child. The labour was tedious^ and when 1 made a vaginal 
examination, I discovered the cause of tediousness to be a con- 
tracted pelvis. I found the os uteri dilated, and the head of 
the child lying at the brim of the pelvis. I applied the long 
forceps, but not succeeding in bringing the head down, I deter- 
mined upon using the perforator and crotchet. The child deli- 
vered, \ divided the funis : it was of the common length, and 
Was not entwined round any part of the child. In about half 
an hour the poor woman said she had a ** violent pain, and the 
after-birth was coming.** As I was engaged with the instru- 
ments I desired Mrs. Jeal to ascertain whether this was the case. 
She was then absent from the bed, but at my request she went 
to make the examination, and immediately exclaimed, <' there 
is another child, for the head Is advancing.** I made the ne- 
cessary examination, and found a large globular tumour, hard 
and resistant, with the placenta attached nearly in the centre. 
This I at once discovered to be an inverted uterus. The fundus 
had partially passed through the os uteri. I introduced the 
hatid into the vagina, and. pushed the tumour upwards without 
much diflSculty. The depending part of the tumour seemed to 
retire from my hand with considerable force. I then deta<ihed 
the placenta, which was not withdrawn until I was assured that 
the uterus would contract. There was no flooding, faintness, 
or convulsion, and the patient recovered without an untoward' 
symptom. 

Case VI. — (Communicated by a friend.) The subject of 
the present case was about 40 to 43 years of age. Site has> 
had a number of children. Her complexion is sallow, and 
habit leucophlegmatic. During the whole period of this, her 
last pregnancy, she suflfered very much from irritation in the 
pelvic organs. Her bowels were almost always constipated. 



Mr. Radford on Lnveriion of the Uterus^ 17 

Complained of great weakness during the whole time she car- 
ried the child. When called to her in labour, I was told she 
had suffered grinding pains for several hours. As the pains 
increased^ I proposed to make a vaginal examination. I found 
the OS uteri dilated, and the head of the child low down in the 
pelvis. The labour advanced, and in about four hours after 
my arrival, the child, which was living, was expelled. The 
funis was divided as soon as the respiratory function was es- 
tablished. It was of the ordinary length, and was not twisted 
round any part of the child's body. A discharge of blood now 
occurred, but it was considerably less than what happened in 
two of her former labours. Considerable uterine contraction 
now came on, and the placenta was therefore immediately re- 
moved, and the discharge greatly abated. When I made my 
evening visit I found she had great diflSculty in voiding her urine; 
I therefore passed the catheter ; and at the same time satisfied 
myself that the uterine tumour was to be felt above the pubes. 
She was very low, and grew weaker for two or three days; and 
as the lochial discharge was greater than usual, I was induced 
to make an examination, and found a tumour low down in the 
vagina, and indeed protruding through the os externum. From 
the imperfect information I gained, I at first thought it was 
procidentia uteri. I attempted to return it, but did hot succeed. 
I now proposed a ionsultation, but it was not acceded to until se- 
veral days elapsed, when the pain was very great from the trials 
made to reduce it. An eminent surgeon was now consulted, 
and agreeing with me that the case was most serious, proposed 
having a third party brought into consultation. Agreeing that 
it was a case of inversion, we determined to attempt the reduc- 
tion, and in about fifteen minutes it was happily accomplished. 
She has gone on very favourably ever since, presenting no 
threatening symptoms ; only complaining of extreme weakness, 
and a slightly irritable bladder. 

In the case above detailed there was no effort made to re- 
move the placenta by pulling the fimis. 

VOL. XII. NO. 34. D 



18 Mr. Radford on Inversion of the Uterus. 

Cases are only valuable inasmuch as tbey illustrate practical 
points. Those above detailed prove that inversion is easily re- 
mediable by perseverance at the time of its occurrence^ and 
also after the lapse of several days. This happy result^ in con- 
nexion with others^ I shall have to allude to, is much more en- 
couraging to the practitioner than the opinion of Dr. Denman 
would lead him to anticipate. 

This accident has been attributed to causes purely mecha- 
nical, the uterus being unresisting, and passively obedient to 
their influence. The practice of pulling too early and violently 
at the funis, after the expulsion of the child, before the uterus 
has contracted, so as to detach and expel the placenta, has been 
generally considered as the cause of inversion. But we know 
that the accident happens before any force has been applied to 
the funis.* In Case IV. the descent was so rapid and forcible 
through the pelvis and os externum, that it would have been 
quite impossible to resist the unnatural action by which the or- 
gan was carried down.t It has occurred, when the patient had 
been delivered of a dead child, the funis so putrid as to break 
with a very slight efrort.t It has been found before the cord 
was separated, and the child given to the nurse.§ In the prac- 
tice of Ruysch this circumstance took place after he had ex- 
tracted a dead child, &c|| These circumstances show that 
there is a power inherent in the uterus to become inverted. 
The pulling of the funis is so common a practice amongst our 
midwives, and done without the least consideration of the con» 
dition of the uterus, that if it was so frequent a cause as is 



* Vide caves already cited. Also Dr. Albers Danoaa's Anoals of Medicioe» 
YoL ▼. p. 390. Mr. Dickenson's case, Med. Gaaette, No. 373. Mr. Windsor, 
Med. Cbir. Trans. yoU x* p. 359. Dr. Dewees' Cases, Essays on various Subjects 
connected with Midwifery. 

t Vide Smith, Med. and Pbys. Journal, vol. vi. p. 503. 

X Brown, Memoirs of lA>ndon Medical Society, vol. y. p. 292. 

$ Welsh, Med. and Phys. Journal, yoI. y. p. 451. 

H Observation, Anatom. Chirurg. Obe. x. p. 13. Translation, p. 34. 



Mr. Radford on Inversion of the Uterus. 19 

usually stated^ iiiversiony instead of being one of the most rare^ 
would be the most common accident in midwifery. Some 
writers have thought that a short funis is a frequent cause of 
inversion ; whilst others thinks in order to act, it must be in* 
serted in the centre of tlie placenta^ and tliat this mass must be 
attached to the fundus uteri.* Now it is evident, if brevity of 
the cord is capable of producing so serious an accident, these 
peculiarities will greatly add to its influence. But amongst the 
published cases of inversion there is, so far as the writer knows, 
but one where this shortness existed. f It often occurs without 
diminished length in the cord ; whilst, on the contrary, children 
are frequently bom where it is very short, and yet no such 
event happens. $ The funis has been Fuptured,§ and tlie pla- 
centa disrupted,|| and yet the utenis was not inverted. 

In order that the causes which have been now alluded to, 
could operate effectually to produce inversion, there must be 
such condition of the uterus present, that it becomes tacitly 
obedient to their influence. Most systematic writers, as also 
others, have supposed such to be the case. They have spid 
that the uterus, previous to inversion, is in a state of extreme 
relaxation, exhaustion, or collapse, and that it offers no resis- 
tance to any force applied by the funi8.1f These opinions are 

* Gardien. 

t Dr. King's Cue. Several coils of the funis were round the neck of the child, 
ftnd it was also twisted round one arm. Glasgow Journal, vol. i. p. 17. 

t The inquiries and deductions of the writer's respected friend. Dr. Churchill, 
are strong evidence of the truth of the above statement ', and he is glad to have his 
opinions corroborated by so respectable a practitioner. 

$ Med. and Phjs. Journal, vol. Uv. p. 205. Gi£Sud's Cases, Nos. 93, 127, 
1 75, 194, 199. Perfect's Cases, Nos. 109, 132. 

I Ramsbotham, Practical Observations, Part. I. Cases, Nos. 28, 31, 32, 
33, 34. 

T Mr. Inglebj, Facto and Cases in Obstetric Med. p. 22 1. Dr. James, Ame- 
rican edition of Burns, Note 104. Dr. C. M. Claik, Observations, p. 15. London 
Practice of Midwifery, p. 310 : Dr. Jewell, Dr. Denmao, Dn Francis, Dr. Gooch, 
Dr. Aitkeo, Dr. Spence, &c. &c. 



20 Mr. Radford on Inversion of the Uterus. 

at variance with that of the writer,* which is founded upon an 
analysis of the cases published and those detailed in this paper. 
The fundus came down with strong bearing pain, in some cases 
extremely violent In Cases Nos. II., IV., V., detailed in this 
paper, the protrusion was forcible, and attended with a strong 
bearing down pain. In Dr. Cleghorn*s case,t " the pains, so 
far from being alleviated by delivery, grew every moment more 
intense ; those of the back, in particular, were so excruciating, 
and the throes, which the women call bearing pains, so violent, 
that the patient, worn out with fatigue and suffering, became al- 
ternately insensible and delirious." And in Mr. Brown's case 
the pains are described as becoming ^^ more excessive, with a 
degree of bearing down hardly to be conceived, and an actual 
inversion of the uterus took place." Violent pain, bearing 
down, and forcible protrusion, are not characteristic of re- 
laxation or collapse of the uterus, but are here, as before the 
expulsion of the child, the consequence of contraction. Other 
circumstances show that the uterus is not in a state of relaxation. 
Such is its distention previous to labour, that great contraction 
must take place to enable the inverted fundus to pass down 
through the pelvis and os externum. The fundus and body 
must at least be so contracted as to represent a body not larger 
than the size of a child's head, as we know that there is such an 
exact relation between the pelvis and the foetal head. The tu- 
mour has frequently been mistaken for the head of a second 
child,^ and in some instances severely used before the error has 
been discovered ;§ in others it has been compared in size to it.|| 

* Dr. Deweet' Essays. 

t Medical ComineDtaries, vol. ii. p. 226. Brown, Memoirs of London Me- 
dical Society, vol. v. p. 202. White's, C, Treatise, p. 431. Smith, Med. and 
Phys. Journal, vol. vi. p. 502. White, Med. Comment, vol. xx. p. 248. Ha- 
milton, Med. Comment, vol. xvi. p. 316. 

t Cases II. and V. 

$ Bartholin. Note in Burn's System of Midwifery. Ruysch. Dr. Hamilton, 
Med. Commentaries, vol. 16. Cowley, London Med. Journal, vol. vi. p. 366. 

II Mr. Dickenson's Case, Medical Gazette, No. 372, p. 351. Doctor King, 
Glasgow Journal, vol. i. p. 172. 



Mr. Radford on Inversion of the Uterus, 21 

A tumour which can be mistaken for a child's head^ must have 
similar tangible properties^ as firmness^ hardness^ &c. It has 
been described as the size of a fist/ of a large pear ;t it h^ 
been compared to a printer's ball^^ it has been found between 
the thighs of the patient the size of a foot-ball i§ compaired in 
size and ^pe of the indentation at the bottom of a blackin,^ 
bottle ;|| and in one case after death it was found resembling 
'' a cup with a number of plicas or folds round it^ and was so 
strongly contracted as to require the utmost efforts of myself 
and son^ &c. to reduce it^ Scc^ll Mr. Ingleby says, ** The va- 
gina was filled by a very bulky round tumour^ Sec., and resem- 
bling a very large sized polypus.** Dr. Ramsbotham sayii^ 
^^the inverted uterus, which had now become flaccid, during 
life it had been firm and resistant. "ff 

It appears to the writer that the uterine pain, diminution of 
bulk, firm, resisting feel, sudden formation, and rapid protrusion, 
warrant him in the deduction, that Htkefundia and body of the 
uterus, so far from being in a state of collapse or relaxation, 
are really in a state of unnatural excitement and action. But 
this is not the ca^e with the os uteri ; on the contrary, it is soft 
and yielding, as we find that it oflfers no resistance to the 
coming down of the tumour, whose protrusion is forcible and 
rapid. If these statements be true, it is evident that the fundus 
and OS uteri are in directly opposite conditions ; the former }a 
in a state of violent contraction, the latter in a state of relaxation ; 
and that this relative difference in these two parts of the organ 
is indispensably necessary to exist where inversion occurs. 

• Larootte, Treatise, p. 497. Obs. 384. 

t Dr. Hooter, Anoals of Medicioe, toI. iv. p. 367. 

t White, Med. Comment, vol. xz. p. 247. 

f Smellie's Cases ; Collect. 44, Case 4, p. 445. 

H Dr. Dewees' Essays, &c. Case 1 . 

f Dr. Merriman's Synopsis, Appendix, Case 3. 

«* FacU and Cases, p. 927. ff Practical Obseryations, Caso 24. 



22 Mr. Radford on Inversion of the Uterus. 

Dr. Douglass has endeavoured to prove that the structure and 
economy of the fundus and body of the uterus are difierent 
from that of the cervix.* 

In natural labour the escape of the liquor amnii is succeeded 
by a permanent and general contraction of the uterus upon the 
child^ increased as the several parts of its body are expelled. 
Now the fundus and body act powerfully^ whilst the os uteri is 
completely overcome and obliterated. But when the child is 
expelled^ this opening is diminished by the lips becoming again 
apparent^ and which are to be felt soft and projecting. This 
change is also shewn in twin labours^ for however soon the se- 
cond child succeeds to the firsts the uterine orifice offers a 
slight resistance ; and in the expulsion of the placenta^ as it 
passes through this openings slight uneasiness^ pain^ and bear- 
ing down^ are the result But sometimes the regular and uni- 
form contraction does not take place^ from causes obscure ; and 
many inconveniences follow, f There are several varieties of 
irregular uterine contraction^ and in all^ some part of the organ 
must be in a state of weakened action^ whilst another is in a 
highly excited condition. It is not essential to inquire here 
which of these two states lays the foundation of the mischief. 
The uterus is divided^ in hour-glass contraction^ into two com- 
partments : in the upper the placenta is uniformly found. A 
contraction sometimes takes place in the body and cervix^ leav- 
ing a chamber at the fundus, in which also the placenta is 
always found. There again occurs a contraction in the os 
uteri, with deficient action in the body and fundus. This con- 
dition leads to a retention of the placenta, and in some instances 
it takes place after the placenta has been removed, giving rise 
to internal flooding. There are states of the uterus where some 
portion or portions contract with greater force than the rest. 
Now it appears to the writer that inversion is another instance 

* Medical Transtctioiu, vol. vi. p. 379. 
t Dr. Douglass, Med. Trans, vol. vi. 



Mr. Radford on Inversion of the Uterus. 23 

of irregular contraction^ in which the fundus contracts power- 
fully, whilst the cervix and os uteri are in a state of atony. It 
is obvious that if the fundus and body continued their action 
after the expulsion of the child, before the cervix and os uteri 
liave regained their proper powers, that an inversion must take 
place. We find this exemplified in other organs ; the power of 
expulsion is increased in proportion to the relaxation of their 
sphincters. Certain states of the bladder and of the rectum 
are examples. In natural labour the principle is well illus- 
trated : and in the management of many cases of protraction, 
our treatment is particularly directed to the object of relaxing 
the orifice, and thereby increasing the energy of the other part 
of the uterus. 

If the writer is not mistaken, the case related by his re- 
spected friend, Mr. Ingleby of Birmingham, is a further evi- 
dence of the view he has taken as to the excited state of some 
particular parXs of the uterus when it becomes inverted ; and 
although his inference differs from that of this highly respec- 
table practitioner, yet he will, without further apology, tran- 
scribe the case. 

*^ I was compelled. In conjunction with another practitioner, 
to apply the forceps under the disadvantage of uterine inertia ; 
after the delivery of the child, there was no tendency to expel 
the placenta, but a portion of the mass having separated, a 
slight effort was made by the funis. The placenta descended 
considerably beyond the os internum, together with a quantity 
of the uterus, apparently the whole of its right side, the left 
not being sensibly depressed. Flooding ensued. At the moment 
we were rather perplexed; but the nature of the displacement 
became evident, and the inverted part was immediately re- 
turned, together with the placenta. The adherent portion of 
the mass was then separated without delay, and the case treated 
in the usual manner.''* Again, the way in which the fundus 

* FacUand Cases in Obstetric Medicine, p. 222. 



24 Mr. Rkdford on Inversion of the Uterus. 

retired from the hand in Cases II. and V. and also in those 
related by Dr. Merriman,* are further illustration. 

In labour, if it is to proceed regularly, a just balance must 
exist between the several parts of the uterus ; and anything 
which irritates the fundus or os uteri, during the process, to 
produce violent action or rapid dilatation, are causes of irregular 
contraction. 

In the cases of inversion which have been detailed, we find 
numerous sources of irritation mentioned, which are equal to 
the production of irregular contraction. Hastening the la- 
bourjt artificial rupture of the membranes;:!! patient delivered 
in a sitting position ;§ rapid labour ;|| mental alarm and agi- 
tation ;1f hasty extraction of the placenta ;♦* erect position durin 
delivery ;tt leaning forwards over the bed during labour;: 
premature giving way of the membranes ;§§ tedious labour ; 
pulling at the funis ;1[1[ to these statements many more might 
be adduced, but they are sufiicient to shew that great misma- 
nagement has existed. They are causes which are capable of 
of hastening or interrupting the parturient process. Many of 
these circumstances are introduced when put in force to increase 
the power of the pains during labour ; they have a direct ten- 
dency to effect a too rapid, premature, and forcible dilatation 



O 



* Synopsis' Appendix, No. 30, Cases 1, 2, 3. 

f Lofter, Medical and Physical Journal, vol. ii. p. 207. 

I Welsh, Do. Do. vol. v. p. 460. 

$ Charles White's Treatise, &c. p. 429, alto Case IV. of this paper. 

I Dr. Albers' Annals of Medicine, vol. v. p. 391, Dr. Ramsbotham's Case, 
Dr. Dewees' Cases, 1, 3. 

% Smith, Medical and Physical Journal, voL vi. p. 503. 

** Dr. Hamilton, Medical Commun., vol. xvi. p. 616» Lamotte. 

If Dr. Cleghorn, Med. Commun. vol. ii. 

tt Cate II. 

$$ Dr. Dewees' 2nd. Dr. King. 

II II Cases IV. and V. of this ptper._Dr. Belcombe ; Dr. Perfect's Cases, 
71 and 72. 

ff Most systematic writers. 



Mr. Carmichaers Ohserv(Uions,'Sfc, 25 

of the OS uteris and not a less tendency to produce spasmodic 
and irregular contraction in the womb. 

The rapid extraction of the child's body after the head is 
expelled^ is a practice fraught with evil^ it is one which the 
writer has witnessed frequently, notwithstanding the strong 
language used upon this subject, and the able exposition of our 
late highly gifted townsman, Mr. Charles White. The tem- 
porary cessation of the expulsive eflTorts after the extrication of 
the head, is of the utmost importance to the female; and the 
abrupt removal of the stimulus of distention given to the os 
uteri, by the shoulders and body of the child, leaves the organ 
without excitement before it has recovered its power of con- 
traction. Fainting and hemorrhage frequently occur in conse- 
quence of the hasty extraction of the child's body, and result 
from the sudden removal of uterine and abdominal distention. 

From what has been stated, it may be concluded, that 
quick labour, whether natural or artificial, a disturbance of 
this process in any of its stages, or any of those circumstances 
which produce irregular contraction of the uterus, are singly, or 
combined, the causes of inversion. 

{To be contimied.) 



Art. III. — Observations on Dr. Abraham Colles*s Work 
" on the Venereal Disease^ and on the Use of Mercury.^ 
By Richard Carmichael, M.R.I.A., Honorary Mem- 
ber of the Royal Academy of Medicine of France, &c. &c., 
and Consulting Surgeon of the Richmond Surgical Hospi- 
tal, &c. &c. 

If the *' Practical Observations on the Venereal Disease, and 
on the use of Mercury," lately published, had come from the 
pen of a person less influential than that of my fHend, Doctor 
A. CoUes, 1 should have allowed them to pass without any re- 
marks of mine ; but his doctrines are so much in opposition to 

VOL. XII. NO. 34. E 



26 Mr. Carmichaers Observations on 

those which I espouse, that althou^ he has not honoured me 
so far as to notice any of my published ojnnions on the subject, 
yet I feel that his observations have been in many places so point* 
edly opposed to them^ that I should be deficient, not only in that 
just portion of amour propre, which every man ought to possess, 
but in my duty towards the public, were I to allow his to pass 
unheeded, and to permit others to suppose that I had changed 
my mind, or acquiesced in doctrines which have not even the 
allurement of novelty to recommend them. 

I trust that the observations I am about to make will^ be 
found devoid of all the acrimony which a desire to achieve a 
triumph is so likely to induce, but that they will be made in that 
cool spirit of philosophical investigation, where the object alone 
is to ascertain a truth of considerable practical importance; and 
I beg particularly of the author, not to consider them in the 
light of an attack upon his opinions, but in that of a defence of 
my own. 

The first passage, in the import of which T cannot agree, occurs 
in the first chapter, which treats on the ** Natural History of the 
Venereal Disease." In it we find John Hunter eulogized in the 
terms he so amply deserves, as having ascertained many important 
facts relative to the natural history of the venereal disease not pre- 
viously known. But then, as the author observes, he left much for 
his siiccessors to achieve, and exclaims, ^'does it not appear 
strange, that subsequent writers have not made some efforts to 
supply those deficiencies*" He then proceeds to account for the 
little progress that has been made in this inquiry, as arising from 
.the universal exhibition of mercury, which interferes with the 
natural progress of venereal complaints; for*' every practitioner is 
so impressed," he observes, " with the sense of duty to do all 
in his power for the relief of his patient, that he cannot, con- 
sistently with that feeling, withhold such medicine, or refirain 
from such means as may be best adapted to ^e case."* Now 

_ .m. III II 1 ■ I ■ ———I ■ ^——1 ■ i^— — 

* CoUes, p. 4. 



Dr. A. Colles's fVork on the Venerecd Disease* 27 

this conscientious feeling has^ no doubt^ prevented ojur author 
from taking any steps towards ascertaining the natural progress 
of venereal complaints^ when not interfered with ; but as a feelr 
ing^ perhaps as strong, has prevented others from liaving re- 
course to mercpry in many forms of the venereal disease, so we 
must look to the observations of the latt^, or to those who ab* 
stain altogether from the use of mercury, for information on the 
point in question. And I would here beg leave to ask, has no 
useful additional information in tlie natural history of those di^ 
eases been obtained since Hunter's time, by those practitioners 
who refrain from the use of mercury ? Is not the classificatiofi 
alone of the various forms of venereal disease, grounded ou the 
nature of the eruption, a great and important step towards a 
just knowledge of their natural history ? In Hunter's, work, we 
find these eruptions all jumbled together under the general 
term of copper-coloured blotches, which' is as little significant of 
their character as the term dartre, so generally applied by our 
neighbours to every variety of cutaneous disease. In Hunter 
on the venereal, we find no mention of papulaa, pustules, tuber- 
cles, rupia, psoriasis, or lepra ; all those forms of eruption, in- 
dicative of different forms of the disease, and often requiring 
diflTerent modes of treatment, are all classed under the one 
general and undistinguishable term of copper-coloured scaly 
blotches. Now Hunter is not to be accused of want of discri- 
mination for this omission ; because, at the time in which he 
lived, there was but little precise knowledge, and no accuracy 
of nomenclature, respecting cutaneous eruptions. But when 
the profession became enlightened on this subject, chiefly by 
the labours of Dr. Willan, the information thus obtained was 
applied with manifest utility towards a just classification of the 
diflTerent forms of venereal disease. 

That a classification, grounded on the character of the erup- 
tion, is not only in accordance with nature, but the most prac- 
tically useful one which could be devised, is apparent from the 
following circumstances :-t- 



28 Mr. Carmichaers Observations on 

Ist. When a practitioner meeta with a patient affected with 
a papular eruption, either in its early stage, when it presents 
itself in the form of pimples with accnminated heads, containing 
matter ; or in its advanced stage, when the spots have desqua- 
mated, and present one of the appearances which Hunter calls 
copper-coloured blotches, he may be certain that he has only a 
disease of easy management to contend with, and that under 
suitable treatment, he may assure his patient with confidence of 
a certain and speedy recovery. 

2ndly. If we meet with a pustular eruption which termi- 
nates in superficial ulcers and not in desquamation, we may 
be certain that we have a much more formidable disease to 
manage. 

3rdly. If there is offered to our consideration a case of pus- 
tular eruption, mixed with tubercles, which terminate in deep 
tdcers which spread into a phagedcenic margin, and form those 
crusts termed rupia, we may be certain that we have the most 
unmanageable and destructive form of venereal disease to con- 
tend with. For under the most judicious mode of treatment, 
we too often fail in curing the malady, which annually destroys 
numbers, after enduring a lingering and loathsome catalogue of 
disgusting ailments. For it is in this form of the disease that 
we meet with extensive ulceration engaging the velum, uvula, 
tonsils, and back of the pharynx where it lies upon the bodies 
of the vertebras, ulceration of the nares, destruction of the bones 
of the nose, and also ulceration of the larynx, the usual precursor 
of laryngeal phthisis. 

4thly. The scaly eruption comprising psoriasis and lepra, 
* is a form of the disease which is in general manageable ; for un- 
like the pustular and phagedsenic forms of venereal, it yields 
with certainty and quickness to the influence of mercury. It may, 
however, be accompanied by deep ulceration of the tonsils, and 
very obstinate nodes ; but whether ulceration of the larynx and 
of the nares attends it, is more than I can say, never having wit- 



Dn A. ColWs IVork on the Fentreid Disease. 29 

nessed it This fonn of the disease^ which^ from the term *^ cop- 
per coloured scaly blotches/* was probably most frequently met 
with in Hunter's time^ is now comparatively seldom to be 
seen. It is often confounded with other forms of venereal enip- 
tion^ because papulae and pustules^ in their desquamating de- 
clining stage^ when the virulence of the disease is considerably 
exhausted^ assume a scaly, copper-coloured appearance ; and 
even nipia evinces the same tendency, when the disease is on the 
wane. But I have never seen an instance (although Mr. CoUes 
adverts to several) of " a papular or scaly eruption degenerating 
into rupia." 

The tendency of all venereal eruptions is, as the disease is 
becoming exhausted, and is gradually yielding to the powers of 
the constitution, to become scaly. And when in this state, no 
matter in what form the eruption commenced, I never saw mer- 
cury do harm, but always observed the most decided and 
quick amendment to follow its adoption, — a general fact which 
must be a great comfort to those who are^ther too indolent, or 
too sceptical, to think it of any consequence to pay attention to 
the precise character of the eruption. 

From the facts above stated, I have a right to deny the jus- 
tice of the sarcasm of our author, that all who treated of the 
venereal disease since Hunter's time, have added no additional 
information relative to its natural history. It is a most im- 
portant practical point, and, coupled with the natural history 
of venereal complaints, to be able by an accurate diagnosis, 
grounded on the character of the eruption, to prognosticate 
the probable event ; to be able to state whether the patient will 
recover in a short time, or whether he may linger for years, and 
finally sink under the disease ; and also from the nature of the 
eruption to be able to decide on the most appropriate mode of 
treatment 

I have not in these observations on the natural history of 
venereal diseases, insisted upon the much disputed point of 



30 Mr, Carmicbaers Observations on 

a particular form of primary ulcer being followed by a particu* 
lar or corresponding form of eruption. And I have refrained 
from doing so^ because^ though my opinions remain unshaken 
on this head^ and are supported by a host of observations^ yet 
as it is still subjudice, I am unwilling to assume it as a fact 
established in the natural history of venereal diseases. 

But notwithstanding this concession^ and that Mr. Colles 
declares, '^ that after a long and careful observation, he had not 
been able to trace particular forms of eruption to particular 
forms of primary ulcers/' I must also declare, that nothing is 
more decidedly connected, in my mind, than the links which 
exist between gonorrhoea virulenta, a patchy excoriation of the 
glands and prepuce, and the simple fungous-looking ulcer 
without induration, with the secondary symptoms — papular erup- 
tion and all its concomitants, as laid down in my work on 
venereal diseases ; and, again, the connexion which exists 
between the primary phagedaenic or sloughing ulcer, with vene- 
real rupia and all its dreaded companions, is equally evident. 

That the papular and phagedsenic forms of venereal disease, 
as described in my work, combine in each a concatenation of 
symptoms both primary and secondary, totally dissimilar in ap- 
pearance, in character, in duration, and insusceptibility of being 
acted upon by medicine, is obvious to any man even of a limited 
experience, and must be acknowledged as such by every candid 
mind solicitous after truth. 

Mr. Colles's reasons for dissenting from this doctrine, 1 shall 
give in his own words : — " Firstly," he says, " I have not unfre- 
quently observed varieties of eruption exist together in the same 
individual ; for example, I have seen small venereal lichen on 
the face, while a large fprm of papular eruption oceupied the 
trunk and the extremities ; sometimes, also, I have found spots 
of a pustulai* character scattered through a general crop of the 
papular eruptions. Secondly, I have noticed, as a very fre- 
quent occurrence, that when the 6rst eruption has been removed, 
either by the use of mercury, or by other means, that the second 



Dr. A. CoUes's Work on the Venereal Disease. 31 

crop haoB proved of a different kind ; thus when the 6rst eruption 
was of that small pimply kind wliich resembles measles, it has 
been succeeded by a papular eruption, and this again by a pus* 
tular crop. And, thirdly, by injudicious treatment ; for example, 
by the excessive use of mercury in bad habits, any one other 
form of eruption may be made to degenerate into one which is 
most obstinate and severe, namely that of rupia." 

To these observations I reply, that small papulae on the face 
and large 'ones on the trunk, in the same individual, do not 
evince any difference in the nature of the eruption on these two 
parts, but only a difference in its intensity. The same objec- 
tion might be urged against the identity of the itch, small-pox, or 
any other eruption, because it happens to be more severe in any 
one part of tlie body than on another. Some explanation is per- 
haps required with respect to the nomenclature of venereal 
eruptions. Papulae have constantly accuminated heads con- 
taining matter, which some might call pustules ; but the true 
diagnostic distinction between venereal papulae and pustules is, 
that the former end in desquamation, the latter in superficial 
ulcers. 

If a case presented itself in which pustules that terminated 
in ulcers were intermixed with papulae, I would say the patient 
was afflicted with the pustular eruption ; always designating it 
by the term which signified the most severe and dangerous spots 
which appear on the patient. For in tlie pustular eruption we 
often meet with papulae, and in the phagedaenic eruption we 
often see the rupia, which marks the disease, intermixed with 
both papulae and pustules ; but the first, in my judgment, indi- 
cates the true nature of the eruption. 

In the same manner, in small-pox, we often observe papulae 
intermixed with the pustules, which latter constitute the charac- 
teristic signs of the disease, for no person thinks of calling small- 
pox a papular, but a puistular, eruption. 

With respect to the second objection, I may briefly observe, 
that tlie tendency of all venereal eruptions in re-appearing. 



32 Mr. Carmichaers Observations on 

either a second, tliird^ or fourth time^ is to assume the scaly 
form. But altliough I liave been many years attending to the 
natural history and the progress of this class of diseases^ I can- 
not call to my recollection a single instance, even under " inju- 
dicious treatment, and the excessive use of mercury," of a papu- 
lar eruption being succeeded by a pustular crop, or this last by 
rupia. 

The successive crops of both the papular and pustular erup- 
tions have, as I have just said, an obvious tendency to assume 
the scaly character, in which they appear like copper-coloured 
blotches, and e.ven rupia itself has the same tendency; but with 
this modification, that the spots exhibit the appearance of raised 
roimded tubercles, of a scaly dark red or copper colour, of which 
we possess many excellent delineations amongst the admirable 
collection of drawings belonging to the Richmond Surgical 
Hospital. 

At page 76, 1 find the following ob8er\'ation — " We shall 
now consider the proper treatment for a case of true venereal 
ulcer, the Hunterian chancre : — The local treatment should, in 
my opinion, be confined to the most bland and mild applica- 
tions, such as cannot in any manner alter the features of the 
ulcer, for I am certain that many useful indications which may 
serve to guide us in the administration of mercury, are to be de- 
rived from observing the changes which these ulcers undergo 
through the agency of that medicine; these changes, and their 
corresponding indications, I shall hereafter advert to. I am fur- 
ther confirmed in this opinion from having observed that little 
or no benefit is derived from a contrary practice ; thus, I have 
known a chancre completely cut out on the first or second day 
after its appearance, yet the occurrence of secondary symptoms 
was not prevented." 

I cannot agree with my esteemed cotemporary in this rea- 
soning or advice ; for although he may have seen a chancre ex- 
tirpated on the first or second day after its appearance, and yet 
secondary symptoms not prevented, yet I have seen, on the con- 



\ 



Dr. A. Colles's Work on the Venereal Disease. 33 

trary, so many hundred instances of primary venereal ulcers 
treated by the free application of lunar caustic^ with the view of 
destroying a surface secreting a morbid poison, which were not 
followed by constitutional symptoms, that I cannot but look 
upon this general exemption, by the mode of treatment men- 
tioned, as a proof that I acted on a right principle. But in 
order to cut off infection, the earlier it is attempted the better. 
We should also recollect, that during the first two or three days, 
and whilst the ulcer is still excavated, and secreting a thin, 
ichorous discharge, it is in its most virulent state, and, therefore, 
most likely to infect the constitution. For we know, from the 
practice of inoculating vaccine and variolous matter, that the 
earlier the poison is taken, and before the matter becomes 
purulent, the more certain we are of imparting the poison;* 
and, therefore, it follows that the sooner we prevent an ulcer 
from secreting a highly infectious matter, the more likely are 
we to prevent the contamination of the system ; and this is of 
more consequence than withholding our hand with the view of 
receiving '' useful indications, which may serve to guide us in 
the administration of mercury." 

Concerning the prevalent exhibition of mercury. Doctor 
CoUes observes : " In my opinion, nothing can more clearly 
establish the claims of mercury to be considered as a specific 
for this disease, than the frequent instances of cures made by it 
in the hands of those who must employ it at random ; and very 
frequently on patients as careless and incautious as the pre- 
scriber is ignorant and pretending. It is wonderful that an en- 
gine so very powerful could have been so long wielded by the 
hands of the inexperienced, the injudicious, the uneducated and 
unprincipled, and yet should not have committed more havoc 
than it has done." But surely Dr. Colles does not mean to as« 

* The MtUfactory experiments of iooculalion of venereal matter, by Mr. 
Evans, detaUed at p. 80, 2nd edition of my work on the Venereal, establishes this 
view of the subject. 

VOL. XII. NO. 34. F 



34 Mr. Carmicliael's Observations an 

sert that mercary has not committed most dreadful havoc in the 
hands he alludes to. There is scarcely a day that we do not 
witness instances eidier in public, or in private practice, of die 
injurious consequences arising from the abuse of this most 
powerful medicine ; but I will not limit this imputation to the 
" injudicious, the uneducated, and the unprincipled," for I as- 
sert, that as long as mercury is blindly administered even by 
the judicious, the educated, and the principled, under the de- 
ceitful and empirical notion that it is a " specif" for the cure of 
all venereal complaints, and not given as a medicine of unequivo- 
cal and ascertained powers, on sound pathological principles, 
we are not likely to improve medicine as a science, enhance 
our own characters, or what is of still more consequence, benefit 
our patients. Are we always to be swamped by the obsolete 
axiom, that mercury is the only and appropriate cure for every 
form of venereal disease ? Mr. Pearson formerly escaped from 
tiie many obstacles he met with in practice that militated against 
this notion, by christening those refractory symptoms that did 
not yield to mercury, syphiloidal, or sequel® of syphilis ; Mr. 
Mathias by calling them mercurial ; Mr. Abemethy, pseudo- 
syphilitic. And now Doctor Colles tells us, that when mercury 
fails it is because it has been ^' injudiciously employed ;" either 
in too small or too large quantities ; '' for too short or too long 
a time;" or that the patient has not been '^ duly prepared for its 
use ;*' or that he has taken it in a negligent manner, '' and not 
under a sufficiently strict regimen." It seems never to enter 
into his mind that when it faib, it may be because Uis an inap^ 
prcpriate or injurious medicine for the form of disease under 
which the patient labours; or that it has been administered at 
an unfavourable period, for instance, during the continuance of 
the eruptive fever. 

Thus at page 83, we find the following observations with 
re(^)ect to the treatment of primary ulcers :-^^^ Although I have 
repeatedly stated, that when ptyalism has been established, the 
further use of mercury becomes comparatively safe, yetjt may 



Dr. A. CoUes's fVork on the Venereal Disease, 34 

happeo, either from the mercury being continued too long^ or too 
largely^ in a weakly system^ or from a state of fever induced by 
other causes, that a chancre which has made some progress 
towards healing, will take an unfavourable turn, and assume a 
phagedfienic or a sloughing disposition." 

Now here the ulcer, it seems, unluckily began to assume a 
phagedaenic or a sloughing disposition, ^* because the patient 
had taken mercury too long or too largely." But if our author 
bad not been blinded by his prejudices, he would have said, 
because mercury is not an ^appropriate or fit remedy for any 
primary ulcer which shows a disposition either to the phage- 
denic, or the sloughing process ; but this would be expecting 
too much, for it would lead to an admission that there is a difier* 
ence in primary ulcers indicating the necessity of different 
modes of treatment Continuing his observations on these ob* 
durate ulcers which so provokingly resist the infallible powers 
of mercury, we read at the next page but one, (85,) that *' about 
twenty years ago, when I had charge of a large number of sol- 
diers labouring under the venereal disease, who were received 
into the attic wards of Stevens's Hospital, I attempted the treat- 
ment of such cases by throwing in mercury largely and sud- 
denly ; but whether it was owing to the want of a judicious 
plan of using mercury, or to the bad habits of the men, induced 
by intemperance and dissipation, I know not ; but I freely ad- 
mit that with many this practice was not successful. ^ However, 
the success of the two plans, that by mercury and that by the 
antiphlogistic regimen, was so evenly balanced at the time the 
military hospital was broken up, that I was quite undecided 
which to prefer. About this time I learned the use of the blaclL 
wash, which has rendered such essential services in the early 
periods of this condition, that I have not since repeated the ex- 
periment of administering mercury through the constitution. 
Many of the cases treated with mercury were cured without the 
slightest destruction of any part, but this was purchased by the 
certain and severe sufiferings of a violent salivation. Some 



36 Mr. Carmichaers Observations on 

escaped with the loss of part of the glands, and some few had the 
penis destroyed down to a level with the pubes. Possibly the mer- 
curial treatment would have been the more frequently successful, 
had I more constantly used venesection and other evacuations as a 
process preparatory to the use of mercury. There is one condition 
of the sloughing penis which I look upon with total despair of 
being able to afiford any means of arresting its progress until it 
has destroyed the entire penis down to the pubes : I mean that 
condition in which the sloughing part is so soft, as to resemble 
melted tallow when beginning to form into a solid. I have 
never seen the progress of this arrested, even for a moment, by 
any local or constitutional means hitherto employed.^ And 
yet, at the very period alluded to by Doctor CoUes, my work 
on venereal diseases was in the hands of every surgeon, and he 
would there have found a number of cases in which this form 
of ulcer was successfully treated, and the absolute necessity em- 
phatically insisted on of abstaining altogether from the use of 
mercury. But I feel grateful for the candour of Doctor CoUes's 
admission ; and although I widely differ from him in my opi- 
iiions, yet 1 have the utmost reliance on the honesty of his state- 
ments. Thus we find, that even in his hands, mercury failed to 
benefit phagedsenic ulcers ; but surely he of all others should 
not attribute this failure either to a neglebt of the preliminaries 
of " venesection and other evacuations ;*' or to an " injudicious 
plan or mode of using it ;" or even to the " bad habits of the 
men." For it is well known that soldiers being well fed, 
cloathed, and exercised, possess far superior constitutions to 
the generality of the inmates of hospitals. His reliance upon 
his favourite medicine, it seems, therefore, would have been 
sadly shaken, had he not at this time learned the use of 
black wash, the well-known combination of calomel and lime 
water. This fortunate discovery saved his confidence in the 
powers of mercury ; and I believe, at the same time, not a 
few unworthy members of society from being reduced to mere 
stumps, if not uprooted altogether from their pelvic origins. 



Dr. A. CoUes*8 Work on the Venereal Disease. 37 

The good eflTects which so frequently arise from a sponta- 
neous hemorrhage in stopping the progress of a phagedsenic 
ulcer, is next adverted to. Tliis fact I particularly stated in my 
work, (at p. 166, second edition,) and therefore recommended 
(at p. 182,) the removal of the jagged and uneven edges of such 
an ulcer by the knife, which induces a bleeding that succeeds 
often in checking its further progress. But as our author does 
not condescend to notice the works of any man since Hunter's 
time, I have no right to complain of his disregarding this, and 
some other points of practice, which I believe originated with 
myself. 

In the next page, (87,) even after the ulcer is induced to 
heal, he recommends a course of mercury, with a view of pro- 
tecting the constitution. Now I beg to protest against this 
practice, as 1 have frequently seen a phagedsenic ulcer, after it 
had been healed, break out afresh, as soon as the mercury had 
affected the system, as if to evince how inimical is its use in this 
form of venereal disease. 

In the same page, we find that a full course of mercury is 
recommended for the cure of chancrous excoriation, — a primary 
affection, which I have mentioned as one of the causes of the 
papular eruption. 

This recommendation, I acknowledge, astonished me ; as I 
thought that such practice had been long since relinquished, 
having myself been in the habit of treating it with some mild 
astringent wash, and gentle aperients, during the last twenty- 
iive years, a practice which usually removed the complaint in 
three or four days, the most obstinate case seldom extending to 
a week ; and I found that constitutional symptoms as seldom 
occurred after.this treatment, as when I had been in the habit 
of using mercury. On looking over the cases which Dr. Colles 
gives as illustrative of his mode of managing those ulcers, we 
fiud that Mr. W. (p. 88) used mercury in large quantities for 
the cure of this simple complaint, and that he even took five 
grains of blue pill, or three grains of calomel, three times a day, 



38 Mr. Carmichaers Observations on 

while he rubbed in mercurial ointment every night The next 
case^ (Mr. B.,) who was affected with so mild an excoriation, 
that he was treated with cold water at first, and afterwards was 
put on a mercurial course, which, however, did not prevent the 
accession of constitutional symptoms. He, however, it appears, 
got worse under the use of mercury, and it was laid aside in 
consequence of an excoriation occurring about tlie anus. The 
patient then got well, and had not any return of his venereal 
symptoms* 

Now, those who have been dosed with a full course of mer^ 
cury know full well that it is really no joke, and it appears to 
me to be rather too serious a measure to inflict for a complaint, 
which, under the mild means pointed out, may be effectually 
cured in a few days ; particularly as we find, by Dr. CoUes's 
own shewing, that mercury, however largely given, is not al- 
ways successful in preventing the accession of constitutional 
symptoms. 

Before I take my leave of his observations on primary ul- 
cers, I must make some strictures on the following passage, 
which was obviously intended as a hit at my peccadilloes. 

''I shall not attempt any farther description of the various 
primary venereal ulcers which are daily to be met with; 
much less shall I undertake any classification of their endless 
varieties, or of the course with which each peculiar form has 
been supposed to run. They will be found to differ so con- 
stantly, that very rarely shall we find any two of them to corres- 
pond accurately with each other ; not merely at their commence 
ment do they present such dissimilar characters, but in their dif- 
ferent stages towardslhealing they will be also found to deviate 
most strangely from each other, more particularly so when they 
have been treated by mercury." 

Now, although I perfectly agree with our author that it would 
be impossible to describe the endless varieties of appearances 
which ulcers present, because every ulcer may be modified 
by age, constitution, mode of living, local and eonstitutional 



Dr. A. CoUes's Work on the Venereal Disease. 39 

treatment^ (particularly by irritating applications and mercury^) 
yet I contend there are at least four classes of venereal primary 
ulcers exhibiting, ab imtio, distinct and characteristic appear* 
ances : Ist, the mild fungous-looking ulcer^ devoid of indura- 
tion or pbagedsena ; 2nd, the ulcer with raised defined edges 
and smooth surface, without granulation ; 3rd, the phagedsenic 
and sloughing ulcer ; and 4th, the ulcer with a hardened base, 
or the true syphilitic chancre of Hunter. Now these four 
classes of ulcers ouiy be so altered by the causes I have men- 
tioned as to present interminable varieties ; yet when we re- 
move the inflammation, and wait until the mercurial irritation 
(the most common causes of these varieties) subside, we will in 
almost all cases be aUe to recognise, in the ulcer under conside- 
ration, one or other of these four venereal classes. 

We now come to the chapter which treats of venereal affec- 
tions of the throat, and we find that our author attributes the 
great variety of ulcers in this part to the manner in which mer^ 
cury has been employed. But it is better to let him speak for 
himself. 

^' In my judgment^ the great varieties in the appearances 
and nature of venereal sore throats, are occasioned by the man- 
ner in which mercury has been used, either for the cure of pri- 
mary, or for the treatment of the secondary symptoms. No 
doubt when mercury is used injudiciously, and in a manner un- 
suited to the general heal& and condition of a patient, we 
shall find that it causes more mischief, and produces more 
strange changes in the venereal ulcers of the tliroat, if the pa- 
tient be of a highly scrofulous, or of a very delicate habit, 
than if he be of a vigorous and healthy constitution." 

Now this conclusion of our ttuthor is completely subverted 
by the &cts whidi the aati-meraurial treatment has enabled us 
to observe ; and therefore, as I before said^ it is only amongst 
the aati^mercurialists that we can learn any thing certain about 
the natural history of the disease. For we meet with great va- 
rieties of venereal sore duroats in those cases where not a grain 



40 Mr. Carmichaers Observations on 

of mercury had been used, and varying in mildness or severity 
in correspondence with that of the eruption which precedes or 
accompanies them. These have already been noticed in this 
paper, and sufficiently enlarged upon in my work on venereal 
diseases. 

But I acknowledge that the injudicious use of mercury in 
cases unfitted for exhibition multiplies, ad infinitum^ not only 
the variety but the severity of the ulceration. And when our 
author recommends a course of mercury for every venereal sore 
throat (for he does not acknowledge distinctions) ^^ of eight or 
ten weeks' duration,** (p. 122,) we may readily conclude what the 
result must be in the papular or phagedaenic form of the disease. 
In the first it is not only unnecessary and injurious, but in 
the latter such a sweeping recommendation is absolutely de- 
structive. 

The case of James Johnson, (p. 133,) admitted Jan. 10th, 
is an excellent sample of the phagedaenic venereal disease : 
rupia, and dark-brown scabs on the forehead, eye-brows, and 
nose, and scattered over the entire body. " The arches of the 
palate, uvula, and tonsils deeply ulcerated ; the entire surface 
of the pharynx converted into, or covered by a soft slough, like 
half-boiled flummery, great emaciation, and weakness.** This 
man was repeatedly salivated, before he was admitted into Ste- 
vens's Hospital, in other institutions. He was treated with 
sarsaparilla, nitrous acid, and lotions of nitrate of silver. On 
the 26th, ten grains of mercurial ointment were ordered to be 
rubbed in ; the other medicines to be continued. 

Feb. 6th. The ten grains of ointment were used only every 
second nighty when diarrhoea set in, and the usual remedies for 
it were directed. We are not told whether the ointment was 
continued; but we find the ulcers were nearly healed; and 
'^ though he swallowed well, the fluid regurgitated through his 
nostrib whenever he drinks; and that for ten days past has 
complained of pains, &c., profuse night sweats, sleeps badly, 
appetite declining." The author then observes, '^ it is unneces- 



Dr. A. CoUes's Work on the FeneretU Disease. 41 

sary to prosecute the details of this case farther." I believe 
not And this is an instance selected as an illustration of the 
successful exhibition of mercury ! Verily a man must have un- 
bounded faith in his panacea^ who could produce the treatment 
of this case as an inducement worthy of imitation. The amend- 
ment is attributed obviously to the ten grains of mercurial oint- 
ment rubbed in every night for ten nights, and afterwards only 
every second nighty although^ at the same time^ sarsaparilla^ ni- 
trous acid^ and strong local remedies were employed. 

The case which follows, (p. 138,) of an apothecary, who had 
a similar ulcer of his throat, so deep and extensive as to cause 
exfoliation of the ring of the first vertebra, is as strong an illus- 
tration as I could wish of the ill effects of mercury in this form 
of the disease. But I shall not make farther observations upon 
these and many other cases equally to my purpose; but merely 
mention my susprise, that if a judicious use of mercury is capable 
of curing the phagedaenic venereal disease, how it happens that 
we are seldom without some cases of this form of the malady in 
the Richmond Hospital, which had been previously many 
months in Stevens's Hospital, where, no doubt, mercury had 
been tried in the most *^ judicious manner." Now, I do not 
mention this by way of triumph, but as a fact, to show that mer- 
cury is not the appropriate remedy for this form of venereal dis- 
ease ; nay, that it is positively injurious and destructive. 

In reply to this, I perhaps may be told that many patients 
are admitted into Stevens's from the Richmond Hospital — 
unsuccessful instances of the non-mercurial treatment If so, I 
shall not feel in the slightest degree hurt by such a rejoinder ; 
only premising this, that we of the Richmond are only so far 
non-mercurialists, that we do not give mercury in every form, or 
in every stage of venereal complaints, nor in any, except those 
few in which its use may be resorted to with advantage, as dis- 
tinctly pointed out in my work. 

In Chapter X. our author contends for the use of mercury 
in venereal hectic fever, and also in that fever which precedes 

VOL. XII. NO. 34. G 



42 Mr. Carmichaers ObservaHons on 

and accompanies venereal eruptions. His words are : " I be- 
lieve it is a pretty prevalent opinion at the present] day, that 
when a venereal eruption Is coming out, we should withhold 
mercury until the eruption be completed, lest we interfere with 
or interrupt that process. Another reascHi for withholding this 
medicine in such cases is, that the fever which accompanies the 
eruption is considered as unfriendly to the anti-venereal action 
of mercury. Now I am convinced, by repeated observations, that 
this rule not only may be departed from, but that it cannot be 
followed with advantage to the patient." 

This doctrine is supported by some cases, in all of which 
mercury was given during the eruptive fever in minute doses ; 
for instance, two or three grains of blue pill once or twice a 
day, or ten grains of ointment rubbed in every night, or only 
every second niglit, are the doses he prescribes. When he 
speaks of hectic fever, I presume he alludes to that fever which 
is an attendant upon those constitutional symptoms which ha- 
rass and wear out a frame already nearly exhausted by useless 
efforts to overcome the disease. Now under such circumstances, 
if the eruption were Sfcaly, and thus indicating that the disease 
was obviously on the decline, I should not feel the slightest ob- 
jection to the cautious exhibition of mercury, having, however, 
first tried sarsaparilla in conjunction with the hydriodate of 
potash ; which latter medicine I consider the nK)8t powerful 
aiixiliary for the cure of the constitutional symptoms of the 
phagedaenic disease, that has come into notice since I last pub- 
lished on the venereal. But as to the propriety of exciting m^- 
cnrial action, whilst an eruption is making its appearance, at- 
tended with an eruptive fever, I decidedly dissent, for the fol- 
lowing reasons : 

1st. Repeated observation has convinced me, that we 
lose instead of gaining time by doing so. For if the eruption 
is suddenly checked by the exhibition of mercury, cold, or 
any other cause, it will most probably return again and again in 
successive crops ; a circumstance, of which Doctor CoUes must 



Dr«^ A. CoUes's fVork on the Venereal Disease. 43 

himself have met frequent instances^ and which, I recollect, we 
witnessed more than once together in consultation, upon cas^ 
which he considered, at the time, very harassing and perplex- 
ing, as the patient had previously taken the specific in great 
abundance. 

2ndly. In suppressing the eruption suddenly by the exhibi- 
tion of mercury, the patient is much more liable to nodes and 
afiections of the deep-seated parts, than if a contrary practice 
had been followed; a fact which is strongly supported by the 
published reports of tl)e surgeons of the British Army, on the 
non-mercurial treatment, by which it appears that nodes are 
much kss frequent under the non-mercurial treatment ;* and for 
these reasons I dissent altogether from the four conclusions 
which the author lays before his reader at p. 226, in favour of 
the exhibition of mercury during the eruptive fever. 

The cases detailed as illustrating the beneficial effects of 
mercury under those circumstances cannot be considered as 
affording any support to his position, for before the small doses 
given could affect the system, the eruptive fever had most pro- 
bably declined. Our author himself seems, from the following 
passage, somewhat aware of the injurious effects of mercury 
during the eruptive fever: — '* lliese two febrile states, viz. that 
of hectic and exhaustion, and that of the eruptive fever, require 
that the mercury should be administered in a manner peculiarly 
suited to such conditions. Were we to use mercury with these 
as we do with venereal patients in general, 1 believe we should 
commit most serious mischief. In these cases we should not 
commence with a larger dose than ten gr. of ungt« hydr. fort. 
every morning, or with an equivalent of blue pill ; that is about 
gr. iij. mane nocteque." p. 234. 

* Coonected with these obsenratioDt, it is worth mentioniog, that so early as 
1819, the AriDjf Medical Board, ia its report on the non-mercurial treatment, 
states, that " Where the primary symptoms have been treated with mercury, the 
•eeoodtry symptoms are more severe, and more intractable, than where mercury 
lud not been used for the primary sores." 



44 Mr. Carmichaers Observations on 

And in the next page we find him statitig that three or four 
drachms of ointment are sufficient to produce the most sidutarj 
eRects ; for not only, he observes, ^' are the secondary symptoms 
dispersed by this small quantity, but the general health is pro- 
portionally improved, so that the patient rapidly acquires health 
and strength.** 

It is amusing to find that M. Divergie, chief surgeon of the 
Gros-CailloUy an advocate for the anti-mercurial treatment ex- 
hibited the same minute doses of mercury as our author, but 
altogether under anotlier motive. M. Divergie gave them in 
finessBy to satisfy such patients as imagined they could not be 
cured without that remedy : not that he had himself the slightest 
faith that such doses would be of aoy advantage ; but it is better 
to let him speak for himself. 

'' When at the close of 1814, I became attached as senior 
surgeon to the Val de Grace, I was very desirous to make trials 
for arriving at the same result in the cure of recent venereal 
symptoms, by rejecting the employment of mercurial remedies. 
The principles explained in the works then published on the 
subject, and so accordant with the facts observed by myself, 
were assurances that I should succeed. But more than one ob- 
stacle prevented me from making conveniently, in the treatment 
of the venereal cases, the trials for which I was so anxious. 
Here as every where else, mercury under three forms, ointment, 
liquor, and pills, formed in general the treatment of the primary 
affections. Physicians and patients showed themselves equally 
persuaded that this metal was the only remedy against these 
distempers. To propose publicly a reform would have been 
equivalent to provoking an anathema against me. I was there- 
fore obliged to proceed with reserve. 

"Nevertheless, from 1819 to the month of April, 1835, 
when I quitted the division of the venereal cases, aided by most 
ol* the pupils, I had several opportunities of introducing freely 
in the treatment of this class of patients, the improvements sug- 
gested by experience and reasoning. Tliose who, already vie- 



Dr. A. CoUes's JVork on the Venereal Disease. 45 

tims of the efiects of mercury, refused to take more, when 
symptoms reoaitly contracted brought them again to the hos- 
pital, fell naturally under my care. As to those who believed 
that mercury was the true specific ^ I began mercurial frictions 
in small doses, one drachm every two or three days, after the 
acute stage was over. Already sparingly nutritive regimen, 
local blood-lettings, and rest had effected an important modifi- 
cation. Time passed ; the cure advanced ; and seven or eight 
drachms of mercurial ointment were suflScient to put these sol- 
diers in a condition to quit the hospital after an abode oi thirty 
or thirty-five days. Those, on the contrary, who were sub- 
jected to the ordinary mercurial treatment, used from ybtir to 
five ounces of ointment, without counting the pills of Belloste 
(Ratier^s Formulary, p. 123) taken in the interval between the 
frictions, and left the hospital only after fifty-five or sixty days. 
When the patients suffered themselves to be guided without 
anxiety ais to the mode of treatment, 1 suppressed altogether 
the mercurial preparations; and I arrived nevertheless at the 
same end; that is, of curing thepatient more rapidly than by 
the ordinary method. Instructed by so many observations 
agreeing with those afforded by my civil practice, I no longer 
doubted that recent syphilis might also be cured by simple and 
rational treatment. From this time mercury performed only a 
secondary part in my practice in the city. I soon renounced it 
almost entirely, and treated my patients by the antiphlogistic 
method."* 

The remainder of M. Divergie's communication consists in 
giving the result of his anti -mercurial practice from 1814 to 
1835, and is chiefly composed of tables of the various classes of 
venereal symptoms thus cured, amounting to several thousands ; 
to which I beg to refer the reader as a most important document. 
The difference between M. Divergie and Doctor Colies, in ex- 
hibiting these minute doses of mercury, appears to be this — 



Ed. Med. and Surg. Journal, from Archives G^o^ralei, October, 1835. 



46 Mr. Carmichaers Obiervations on 

that the former deceived bis patients for their advantage — the 
latter deceives himself to the advantage of no one. 

In a work just published by Doctor Oppenbeim^ ** On the 
Treatment of the Venereal Disease without Mercury, together 
with a notice of the antiphlogistic treatment of the disease pur- 
sued in the General Hospital at Hamburgh/' we find that the 
author is a decided advocate for this mode of treatment, and was 
amongst the first who introduced it into the German hospi- 
tals. 

'* He believes that it can be shown from historical data, that 
since the period when mercury became to be universally 
esteemed the proper remedy for the venereal disease, the latter 
has increased in the obstinacy and violence of its symptoms ; 
and he maintains, that when the treatment of it by antiphlo- 
gistic remedies alone shall be generally adopted, the beneficial 
effects produced upon the present as well as the future genera- 
tion, will be scarcely less than those produced from the disco- 
very of vaccination ! 

'^ Notwithstanding the foregoing facts and observations (all 
relating to the antiphlogistic mode of treatment) it has been 
almost universally believed that syphilis can be effectually cured 
only by specifics, at the head of which was ranked, and still is 
ranked by many, mercury. That numerous other remedies and 
plans of treatment have, at different periods^ been proposed, 
will be seen from the previous chapters of this work. I>iet, de- 
pletion, and abstinence, have, indeed, always been considered 
as necessary adjuvants to insure even the efficacy ef their pre- 
sumed speci/ic.^^ 

For this notice of Doctor Oppenheim's work, we are indebted 
to the American Journal of Medical Science, as it has not been 
as yet translated into the EngliA language. From it we find a 
host of evidence in addition to that afforded by the surgeons of 
the British army, in favour of the antiphlogistic mode of treat- 
ment; and I would beg particularly to call the attention of 
Doctor CoUes to the shrewd observations which I have marked 



Dr. A. CoUes's fVork on the Venereal Disease. 47 

in italics. I have now quoted the opinions and practice, re- 
cently published, of two most influential personages, the one in 
France and the other in Germany, directly opposed to those of 
our author, whose great object seems to be, to bring us back to 
the old orthodox faith — that there is no cure for a venereal 
disease but mercury ; and that those modem heresies which 
have led some foolish people to recommend any other means, 
have induced incalculable mischief upon society. Now al- 
though it seems, from various passages, that our author's faith 
remains unshaken in the " specific^'* powers of this mineral, 
yet he has discovered that one-sixth, one-twelflh, nay a twenty- 
fourth part of the doses he was formerly in the habit of pre- 
scribing, will prove as effectual a remedy as the original quan- 
tum ; thus we find in many cases detailed, particularly of the 
phagedsenic venereal disease, characterized by rupia, that ten 
grains of the ointment rubbed in every night, or every second 
night, or three grains of blue pill every night, or every second 
night, will be sufficient to cure the disease. I feel no ob- 
jection to allow our author to ride his hobby as hard as he 
pleases, provided it produces no worse results than this practice. 
I know how strongly he is wedded to early opinions and associ- 
ations, and that I might as well attempt to shake a pious Mus- 
sulman from his faith, that there is no God but Allah, and that 
Mahomet is his prophet, as to endeavour to dissuade my friend 
firom his belief in the infallible powers of mercury over every 
form and every stage of venereal complaints— a belief which 
may aptly be parodied by a doctrine, the orthodoxy of which 
be will not dispute, that *to overcome these maladies, there 
is no God but Mercury, and Abraham is his prophet. 

In Chapter XL, *^ on the Treatment of Syphilis in Scrofu- 
lous Patients,** I find that Dr. Colles still perseveres in the no- 
tion, that those enlarged cervical glands which occur for the first 
time, with tte other symptoms of secondary venereal, are scro- 
fulous. In my work on the former disease, I pointed out their 
occurrence as analogous and similar to that which takes place 



48 Mr. Carmichaers Observations on 

in other exanthemata ; for all the different forms of the venereal 
appertain to tliis class of diseases. He asks, when these glands 
appear, ^* how are we to treat this complicated case f and then 
he thus replies to himself: " my answer is, that we are to pro- 
ceed exactly in the same manner as if the venereal symptoms 
were uncombined with any such affection ;'' — and my answer 
would be precisely the same, although I do not consider the 
case to be at all complicated — the swelling of the cervical 
glands having arisen from the venereal poison, and not from 
any scrofulous diathesis. But in a truly scrofulous subject, 
with a predisposition to tubercular phthisis, Hunter, in my opi- 
nion, was perfectly right in deprecating the use of mercury, 
particularly when given, as our author recommends in such 
cases, so as to excite a smart ptyalism. Several instances are 
adduced, however, of the success of the mercurial practice ; 
but I rather imagine that the enlarged glands had, in those 
successful cases, a venereal origin. 

Chapter XV. is dedicated to the consideration of the non- 
mercurial treatment of syphilis; of course our author is not likely 
to approve of it, but allows that " fewer of the non-mercurial pa- 
tients complained of affections of the bones, than those who had 
been ineffectually treated by mercury/' Such an admission from 
Dr. Colles cannot but be esteemed of value. He also *^ acknow- 
ledges, that the profession is highly indebted to those who have 
lately introduced the non-mercurial plan of treatment, for we have 
not only acquired a second line of treatment for venereal cases, 
hilt, what is of the highest value, we have been released from an 
inveterate and deep-rooted error — from an unfounded conviction 
that the venereal disease could not be cured by the innate 
powers of the system, unless aided by mercury. I need not 
add, that all the opinions and practices consequent on this pre- 
judice have been subverted.** 

Now, I agree perfectly with him as to the obligations which 
we owe to non.mercurialists ; but I differ nearly as much in 
theory and practice from this class of practitionen, as I do from 



Dr. A. Colles's Work on the Venereal Disease. 49 

the downright mercuriali^. I look upon mercury as a most 
useful medicine for particular forms and particular stages of ve- 
nereal diseases according to the system laid down in my work^ 
which I have now pursued^ both in private and public practice^ 
upwards of twenty-five years, and never had occasion to regret 
my adoption of it But the decided non-mercurialist» in his faults 
oforaission, is perhaps equally erroneous, though not equally in- 
jurious to society as the decided mercurialist, who with one fell 
swoop, and without compunction, blindly consigns every venereal 
case to his powerful, and when thus indiscriminately employed^ 
destructive specific. 

At the conclusion of Dr. Colles's work, is an interesting 
chapter " on the Use of Mercury in Affections of the Nervous 
System,'' which he commences with the following observation : 
<« Every surgeon who has been engaged in the practice of his 
profession during the last twenty years, cannot fail to have re- 
ifiarked the following feet; viz. that, during that period, mer- 
cury has been applied much more frequently to the cure of 
certain diseases, than it formerly was, although its powers over 
these had not been previously acknowledged. How to account 
for the increasing partiality to this medicine, for the cure of 
other diseases, while its use in venereal complaints, for which 
it had so long been considered a specific, has within the same 
period of time been by many practitioners objected to, and by 
some totally abandoned, is a problem not easily to be solved.'* 
He then conjectured that the general application of this medicine 
to diseases not venereal, has been owing to the salutary effects 
whieh it evinced in the treatment of the Walcheren fever. I 
should rather attribute it to the well known beneficial effects of 
merthiry uf)on inflammi^on of the iris, for the first intimation of 
which we are indebted to Dr. Farre, in his letter to the late 
much lamented J. C. Saunders, on the disorganizing effects of 
mercury, pnbliriied upwards of twenty-five years ago. It was 
this first opened my eyes to the benefits likely to result from its 
application in all inflammatory complaints, and from that period 

VOL. xn. Na 34. h 



50 Mr. Carmichaers ObiervaHom on 

I have been in the habit of employing it whereter I suspected 
the existence of internal inflammation. 

In peritonitis, pleuritis, meningitis, periostitis, and lasdy, 
in synovitis, its great utility is firmly established. In the last, or 
inflammation of the joints, my friend Dr. CyBeime has put be- 
yond a doubt, the vast advantages which result from a quick 
mercurialization of the system, in a paper inserted in the 5th 
volume of the Dublin Medical and Surgical Journal, and in the 
4th vol. of the same publication, for September, 1833, 1 inserted 
a paper on " Inflammatory Affections of the Brain and Us 
3fem6ra;}^«,*' containing sixjreniai:kable cases of headaflTections, 
including apoplexyyRil^^fiJtal^ii^^Ji^Ssrf which were treated 
successfully by bli^e^g, nwrtwrtalixirtk^ihe system, and the 
counter-stimtUusI ^ t(gijQLmmti^^%^mem\to the head. The 
unsuccessful caseV thp firstj^^jlgd^ woula probably also have 
had a fortunate tehmiiftlion. were ci&'nQr for the wUfnlness of 
the patient, who disconKmtedJh&'m^cine and my attendance, 
at two distinct intervals, on finding, as he thought, sufficient re- 
lief and amendment from the means employed. 

Amongst observations I made at the time on the cases de- 
tailed, is the following :—^ In the treatment of inflammatory 
affections of the brain and its membranes, next to blood-letting, 
in efficacy, stands, in my opinion, mercurialization of the sys- 
tem. The beneficial effects of this process in stopping the pro- 
gress of inflammation of membranous parts, is most satisfac- 
tbrily demonstrated every day by the exhibition of mercury fi^r 
iritis. Frequently, in this affection, the pain, change of colour, 
and deposition of lymph on the iris, occasioned by the ihfiain- 
mation, begin to disappear, even before the mercury has had 
time to evince its usual effects on the gums of the patient** 

Sinc^ that publication, I have met with a considerable num- 
ber of cases of apoplexy, recent epilepsy, and paralysis, which 
have established, in my opinion, the value of this mode of 
treatment. In inflammation of the brain or its meninges, from 



Dr. A. 001168*8 Work on the Venereal Disease. 51 

accident, it affi)rd8 our best safeguard in protecting the patient 
against the formation of matter and its other consequences; and 
this mode of treating all accidents of tlie head, in which internal 
inflammation is suspected, has been acted on with such success 
in the Richmond Hospital during the last four years, as to in<* 
sure a continuation of this practice. I have this moment, in 
conjunction with Mr. Kavanagh, under pay care a young lady 
remding at Kingstown, who has recovered by this treatment 
from an attack of paraplegia, by which she had totally lost all 
power over the sphincter of the bladder and the lower extremi- 
ties. This young lady had been, previously subject to most ioi- 
tense head-aches, which su6Gciently indicated the seat of the 
disease. 

I therefore hailed with pleasure the con6rmation of my 
opinions and practice contained in this section of Dr. Colles's 
work, in which is detailed some remarkable cases of hemiphle- 
gia, of confusion of the intellect, with tendency to apoplexy, 
gastrodynia, and epilepsy, treated successfully with mercury 
and tartarized antimonial ointment 

But notwithstanding this general adoption of mercury, for 
inflammation of membranous and parenchymatous tissues, I have 
been informed by some eminent apothecaries of this city, of 
long standing, that on a rough calculation there is not a tenth 
of Ae quantity of that medicine ordered now, compared to its 
employment twenty years ago ; a fact which demonstrates the 
great diminution of mercury in the treatment of venereal com- 
plaints* Another fact is, I believe, also admitted by tiie seniors 
of the surgical profession, vis. that we do not now meet in the 
same proportion as formerly, extreme cases of broken down 
constitutions from the combined efiects of venereal and its pre- 
sumed antidote. We have, tiierefore, reason (o conclude that 
the treatment of the disease is, by the majority of practitioners, 
better understood than it was twenty years ago ; but it must be 
admitted that in general practice there is still great room for 
improvement. 



52 Mr. Carmichaers ObaervoHonSy 8fc* 

Notwithstanding that Dr. Colles and I disagree upon many 
points, both in theory and practice, respecting venereal com- 
plaints, yet there are several upon which I give my unqualified 
assent For instance, I agree with him, contrary to the opinion 
of Hunter, ^' that constitutional symptoms are capable of infect- 
ing and communicating the disease." In addition to the testi- 
mony adduced by Dr. Colles on this head, I have met with 
several instances of new married women, whose moral character 
set them above suspicion, who received the disease from their 
husbands, who at the time of connexion had no primary, but had 
secondary symptoms ; and in no other way could I account for 
children before the age of puberty becoming diseased in conse* 
quence of lying in the same beds with persons labouring under 
constitutional eruptions or ulceration. 

His rules for conducting a mercurial course where such is 
advisable, are excellent, and his mode of fumigating by mer- 
curial candles ingenious and suitable. 

The chapter which treats of the venereal disease in infants, 
also contains much novel, useful, and interesting information. 

His mode of treating a chancre at the orifice of the urethra 
with a strong escharotic, such as the white muriate of antimony, 
is decisive and most useful, particularly when the ulcer is of a 
phagedaenic character ; and when stricture of the orifice occurs 
after cicatrization of the ulcer, his peculiar mode of treating the 
strjcture^ as detailed at p. 95, is ingenious, and, I make no 
doubt, efiectual. I also perfectly agree with him, contrary to 
the opinion of Hunter, that chancres sometimes occur in tlie 
urethra ; but this was proved long since by the experiments de- 
tailed by Benjamin Bell. 

Chapter VI. is on a " Disease of the Lymphatic Glands of 
of the Groin attended with peculiar Symptoms.*^ In this afiec- 
tion one or more of the lymphatic glands of the lower or femo- 
ral range are generally the seat of the disease, of which I have 
met with in many instances. It is always attendant upon a deli- 
cate constitution, and rapid pulse. In every case of this de- 



Dr. Churchill on Convalescence after Natural Labour. 53 

scriptionj I have been led to suspect the existence^ or at least a 
strong tendency to tubercular phthisis ; and always directed my 
patients to the sea-side^ and to observe those attentions calcu- 
lated to improve the general health : and I perfectly agree with 
the author, that mercury in such a case would be injudicious and 
most probably destructive. — On the whole^ I am happy in 
stating my opinion, that this treatise contains many useful practi- 
cal lessons ; and that there is no surgeon, however extensive his 
practice may have been, who will not be benefited by a perusal 
of a work obviously the production of a man of extensive expe- 
rience and undoubted talent for observation. 



Art. IV. — Remarks on Convalescence after Natural Labour. 
By Flebtwood Churchill, M. D., Physician to the Western 
Lying-in Hospital, Lecture on Midwifery, &c. 

It may be necessary to offer some apology for occupying the 
atteiUlon of the reader with a subject so common-place as reco- 
very from natural labour, were it not universally acknowledged 
that mankind are most apt to overlook, that which is most con- 
stantly before them. The subject has not occupied very much 
of the attention of those who have published systematic works 
upon midwifery, although it is certainly worthy of it, for it is 
within every one's experience, to be kept in a state of great 
anxiety about the recovery of a patient, who passed through the 
process of parturition in the most favourable manner possible. 
Moreover it not unfrequently happens, that certain symptoms 
arise, the initiative apparently of some serious malady, and 
which yet disappear without active treatment, and are followed 
by no grave consequences. 

Quite recently, tlie ordinary phenomena of the puerperal 
state have been fully discussed, and the appropriate manage- 
ment pointed out by my respected preceptor, Dr. Hamilton of 



54 Or. Churchill on Convalescence after Natural Labour. 

Edinburgh, in the second part of his Practical Observations,* 
which I did not receive until after the rough copy of this paper 
was written. I have consequently rescinded, or but slightly re- 
ferred to, whatever has been so much more ably treated by the 
learned Professor; and I have confined myself to noticing the 
succession in which the changes subsequent to parturition occur, 
and the varicUions from the usual progress of convalescence, 
limiting my observations to such variations as are not the pre- 
cursors of organic disease. 

If we examine a female after delivery, and compare her 
state with what it was before, even during an interval of pain, 
we cannot fail to be struck with the great change which has 
taken place. The act of expelling the child and secundines, 
seems to be attended by a certain shock to the nervous system, 
producing far more marked effects upon the constitution, than 
could have been caused by the mere muscular exertion. The 
skin becomes pale, flabby, nnd moist, the moisture having a pecu- 
liar odour ; the muscles feel softer ; the patient complains of es^- 
haustion rather than fatigue; the organs of sense are unusually 
•susceptible, there being more or less intolerance of light aufi 
sound, and a tendency to headach. The respiration is in some 
cases hurried, in others rather slow and deep, soon after deli- 
very; the functions of the stomach are suspended ; there is np 
appetite, but some thirst, ajad the aQtiQp of the intones is .re- 
tarded. These symptoms are more or less observable in all 
oases, even the most favourable, and where no hemorrhage 
has occurred. If nothing interfere, the nervous system 0»- 
dually recovers its tone, and in no respect is that restoration 
' more manifest, than in its influence upon the various oi^tmic fuoc- 
< lions and secretions. The skin assumes a healthy look and feel ; 
the appetite returns ; and the bowels are evacuated naturally. 
The respiration resumes its accordance with the circulation ; 



^ On tb« Ordinaiy Maofsemtnt of Women after Dtliftiy, p. 1. 



Dr. Churchill on Canvaleseence after Natund Labour. 66 

and 80 far the patient ttiay be considered convalescent There 
are some points^ however, worthy of a somewhat more detailed 
examination, as for instance/ the circnlatton, the state of the 
utems, and mammary glands, &;c. My data for the statements 
which are about to be made, are certiiin tables which have been 
accurately kept, at the W^tem Lying-in Hospital, by my very 
intelligent pupil, Mr. Gibbon. 

If the pulse be counted just before delivery, but during an 
interval of pain, it will generally be found very frequent, almost 
always above 100, sometimes 140. If it be numbered an hour 
or so after delivery, it will be fdund to have fallen below the 
natural standard, say to 60 rand if we examine again after ten or 
twelve hours, we shall find that reaction has taken place, and 
that the pulse is now quicker than when the patient is in health, 
but not s6 quick as it was just previous to delivery. 

Hie amount of the prunary vascular excitement, the de- 
gree of collapse, and the extent of the reaction, depend pardy 
upon the character of the labour, partly upon tfie irritability of 
fhe patient^s Constitution, and partly upon causes which are often 
very obscure, and which it would be foreign to my purpose to 
investigate at present But in almost all the cases I have 
on record, there was a decided relation between the three 
states ; t. e. suppomng the pulse of the patient to have been very 
high before tfie birth of the child, it generally fell very low im- 
mediately afterwards, and rose again proportionally in die 
course of a few hours ; and dee versa, when the primary ex- 
citement was slight, the collapse and succeeding reaction were 
triiaal. Variations from this^ the ordinary course, I shall have 
loccafiSoh to notice by-and-by* A considerable acceleration of 
pulse, with rigors, is observed when the secretion of milk com- 
mences, but this gradually subsides, and the circulation becomes 
quiet and regular. All the observations I have been able to 
makej confirm die accuracy of William Huntbr's remark, &at 
no female, after delivery, can be considered safe, whose pulse 
is not under 160. 



56 Dr. Churchill on Convaletcence after MUural Labour. 

Immediately after delivery, (he uterus contracting, may be 
felt at the lower part of the abdomen, about the size it was at 
the fifth and sixth month of pregnancy. It feels hard and firm, 
and is scarcely at all tender on pressure, except when the after- 
pains are severe. Its bulk is gradually diminidied by succea* 
iive contractions and, according to Dr. Hamilton, by abaorp- 
tion,^ and about the eighth or ninth day, it is within the bony 
pelvis. The after pains occur in paroxysms with distinct inter- 
vals, just like labour pains ; on the occurrence of each, the womb 
becomes hard, is tilted forward, and expels any clots or blood 
which may have been retained in its cavity. 

From the period of delivery there is a constant discharge from 
the womb, lasting two, three, or four weeks, and even longer 
in delicate females. jOn the^r^^ day this appears to be pure 
blood, partly fluid and partly in clots ; the second day it is much 
thinner, and paler, rather a secretion or an infiltration than a 
discharge from open vessels; on the third day it becomes 
more or less slimy, still paler in colour, and generally less in 
quantity : by the sixth or seventh day, the colour changes to a 
dirty yellow or greenish hue, after which it gradually becomes 
colourless, opaque, or transparent, and diminishes in quantity 
until it entirely ceases. It possesses a very peculiar odour, 
which is readily recognized in the atmosphere of the wards of a 
lying>in hospital. Dr. Lowder compared it to the smell offish 
oil. 

Before delivery, the mammary glands generally secrete a 
thin, yellowish fluid, very different from milk ; but cases are 
not unfrequently met with, where proper milk is secreted in 
such abundance, as to enable the female to give suck to the 
child immediately after its birth ; and for children so supplied, 
medicine has been found unnecessary. I have further remarked 
that such females generdly suffer severely from after pains, 
each application of the child to the breast bringing on imme- 
diately a fresh paroxysm. 



• See the EiMjr before quoted, p. 7, 



Dr. Churchill on Convaleicence after Natural Labour. 57 

The secretion of milk before delivery is not the ordinary oc- 
currence^ however; for many hours afterwards the mammary 
sympathy is not excited, but after an interval of from twenty- 
four to fifty hours some uneasiness is felt in the breasts, with 
occasional darting pains, and an augmentation of volume. As 
yet milk is not produced, but the glandular substance feels 
hard and knotty, tlie areola is puSy, and the nipple prominent, 
as it were, erect. In the course of the next eight or ten hoiu^, 
the size and weight of the breasts increase very much, and they 
feel hard and tense. If the child be applied, he will probably 
be able to obtain milk, but less freely than after the lapse of 
a short time, and a little more practice. The flow of milk affords 
great relief to the patient, it diminishes the local distress, lowers 
the pulse, and lessens the heat of skin, which characterijte these 
few days of milk fever. 

These are the principal phenomena which follow natural 
labour, with their successive changes. It now only remains to 
poiqt out. certain variations from this regular course, of suf- 
ficient magnitude to demand our ^attention. And first, of the 
shock inflicted upon the nervous system, and thence upon the 
system generally. I have already said, that I do not believe 
t^is to be the result of the muscular exertion merely, and what- 
ever doubt of this being, the fact q[iay be entertained in the 
more fovourable cases, nope can exist as to the severer ones. 
A due estimate of the nervous shock is of great importance, 
for in almost every instance (when serious disease is not in 
question) the recovery of the patient is in inverse proportion to 
the amount of this disturbance. There are different degrees of 
suffering resulting from it, the more favourable cases exhibit 
very little, in others it is very marked, and in these we may 
observe (in addition to the ordinary symptoms already enume- 
rated) a sun)b8n countenance, laboured, hurried, or panting 
respinMion, great depression, restlessness, small, quick, flutter- 
ing puke; and I have very often observed that the proportion 
between the respiration and circulation is destroyed. In an 

VOL. XII. NO. 34. I 



58 Dr. Churohill on ContxUeseence after Naiur(U Labour. 

extreme case, if the constitution be feeble, the patient may sink 
in the course of a few hours, before inflammation has had time 
to set in, and if a post mortem examination be made, no lesion 
will be found sufficient to account for the death of the patient 
In one such case^ I found the uterus, ovaries, and vagina^ all 
uninjured and free fVom disease, nor was there any lesion of 
any other organ. The patient had sunk, as I have described, 
within a few hours after delivery. But these are extreme cases, 
and fortunately not very common, being chiefly those in which 
the patient has been neglected, or when assistance has been too 
long deferred. 

The length of time which may elapse before a patient ar- 
rives at the maximum of susceptibility to liie nervous shock, 
varies much in different individuals, dependent probaUy upon 
constitutional peculiarities. Labour may go on very long with 
strong women, and yet the shook be very moderate ; with others, 
on the contrary, a few hours of protracted natural labour in- 
volves as much danger as an operation. A third class of 
patients cause great anxiety to the medical attendant, they go 
on for a long time so well, and so iVee from constitutiiHial 
suflbring, that na mischief is anticipated, yet beyond a certain 
point, their power of endurance is exhausted, and they ^ run 
down" with great rapidity. 

There are many oases, however, where the shoek received, 
though fur from being as severe as in some which have beea 
described, is yet quite sufiiciently so to excite uneasi^iess and even 
alarm in the medical attendant, instead of the proportionate 
collapse and reaction which ought lo succeed delivery, we find 
the patient exhausted, panting, and much distressed, witfi a 
quick pulse. Re-action is long bef6re it occurs, or it may take 
place imperfectly or exceseively, and the patient generally 
experiences an unusual degree of weakness, with a tedious 
convalescence. It would be out of place to dwell much upon 
treatment, considering thee xcellent directions given by Dr. 
Hamilton, but I may be allowed to r^mrk en passant^ that 



Dr. Cfaurcbill on Convalmcefice after NaiuHU Labour, 50 

the most obvious remedy for this state of nervous depression 
is not the besU The exhibition of stimulants (as wine^ brandy, 
ftc) to any considerable extent aggrarates the condition of the 
patient, instead of relieving the collapse^ and in very moderate 
quantity only are they admissible. A good dose of opium^ or 
small doses repeated pretty often, will afford more relief; it not 
only gives the patient a chance of sleep, the best restorative of 
all, but even if it fail in this, the system will be quieted, the 
respiration rendered more equable, the pulse slower and more 
natural, and the balance between these two systems restored. 
After a time^ it may be neoess&ry to give some tonic medicine. 
And I think musk will be found one of the most useful. The 
diet of the patient must be carefully adapted to the enfeebled 
condition of the digestive powers. 

To retum.-^The second point mentioned was the state of 
the drcuktion, with the alternation of excitement, eolhpse, and 
reaction. I have just stated one variation from this succession, 
in the case of a severe nervous shock, when the pulse may con- 
time rapid after delivery, instead of fidling. I have often re* 
marked an undue frequency of pulse when the after-pains are 
violent, and as Uie uterus is also somewhat tender on pressure 
in such oases, it requires tact and care to distinguish between 
tfaii state and the commencement of puerperal fever. The 
same observation will apply to the quickening of the circulation 
wUch takes place when lactation commences, and which, in ad* 
riitioDy is aceompaDied by rigors. A careful estimate of all the 
•yaaptoms in either case will generally elucidate the nature of 
^ excitenmity and our observation of the diminution instead 
of the increase of vascular action will decide the question. 
Again, in cases where a coagulum is retained in the uterus, 
U» poise is quickened. I had noticed this repeatedly before 
I could discover the cause, but having found it subside im- 
mediately on the disdiarge of clot8> I have no doubt thot this 
was the cause. 

Lastly, the pnlse will be greatly accelerated, if the patient 
suffer from diarrhoea or gastric disturbance ; and as it is not 



60 Dr. Churdiill on Convalescence after Natural Labour. 

very easy to foresee the issue of such on attack^ the utaiost 
watchfulness will be required. The diagnosis may be very 
obscure, and it may be necessary to adopt certain measures 
rather suited to the attack we fear, than to the disturbiifice 
from which the patient b suffering. Along with the soothing 
atid astringent medicines adapted to the state of the bowels, it 
will not be amissto administer small doses of blue pill or ado- 
mel, in combination with opium. 

With regard to the variations from the ordinary sixe of 
the womb and its gradual decrease ; I have found sometimes, 
on the fourth or fifth day, that its bulk had increased, and Aat 
it felt less firm than previously ; this, combined with the quick 
pidse, has made me fear an attack of hysteritis, nor was this 
fear diminished by the uncomfortable sensations of the patient, 
or by the fact, that in some cases die lochia had suddenly di- 
minished in quantity. Upon applying fomentations of hot 
water or turpentine to the abdomen, a quantity of coagula w^ere 
discharged, and the patient obtained speedy relief. Purgative 
enemata also favour the expulsion of the clots, and in audi 
cases have been given with great benefit. 

It has been already mentioned, that the uterus is not free 
from tenderness in those cases where the after-pains are severe, 
and if it be rudely pressed, the outcry of the patient may mis- 
lead us. It will be observed, however, that this tenderness is 
greatest during each uterine contraction, and that as these sub- 
side, it diminishes. Fomentations to the abdomen will generidly 
mitigate this sensibility, but if the after-pains be se^re, and the 
tenderness considerable, a full dose of laudanum, fdlowed by 
an aromatic purgative, will probably relieve both. 

Perhaps no phenomena in the progress of convalescence 
excite more alarm in the patient's mind, or show mdre the 
value of minute observation on the part of the accoucheur, than 
the variations in the quantity, quality, and odour of the lochia, 
which sometimes occur. The patient will hardly be persuaded 
that such are not the unfailing indicia of organic disease. Yet 
very remarkable changes do occur without any lesion of thd 



Dr. Churchill on Convalescence after Natural Labour. 61 

uterus or vagina. In some cases^ the lochia after decreasing 
for some time, are suddenly discharged in double quantity, 
and of a much brighter colour, but without coagula. This 
generally happens when the patient is permitted to sit up too 
soon. Or it may happen at a later period, in consequence of 
walking about too much. A little extra rest will, however, 
sufliee to restore the patient to her former state. 

Again, the os uteri is sometimes obstructed by a coagulum, 
and the lochia are greatly diminished, or perhaps entirely re- 
tained, until the expulsion of the clot affords an exit to the 
accumulation. 

It has been already stated, that the lochia generally con- 
tinue three or four weeks, according to fhe constitution of the 
patient, but sometimes for six or eight, and then terminate in 
persistent uterine leucorrhoea. This will best be remedied by 
counter-irritation to the sacrum, and the internal exhibition ad 
copaiba, iron, or ergot of rye. 

In connexion witii this subject, I may just mention, that the 
menses frequently return the first -or second period after de- 
livery, without again recurring during lactation. This would 
a|^>ear to be most common after the birth of first children. 

Again, the quantity of the lochia being unaffected, the 
colour may excite alarm ; instead of the transition from red, to a 
pale red, yellowish, or greenish colour, the lochia are sometimes 
of a dark brown, and perhaps more tenacious than usual, or they 
may raddenly become perfectiy colourless, (resembling the dis- 
charge called whites,) but in neither case attended with in- 
convenience or danger. It is very necessary to be on our guard, 
when the lochia become of a redder colour than, from the 
period whidi has elapsed after delivery, they' ought to be, as this 
change may be the precursor of secondary hemorrhage. The 
patient should be confined to the horizontal position, and 
clothed very lightly. 

I have met with two or three instances, where the lochia 
had a very offensive odour, without any other evidence of dis- 



62 Mr. Blaokley'» Ca$e of 

order^ local or general There was neither hyateritu^ nor 
sloughing of the vagina. The patients recovered perfectly. 
In such cases^ it is advisable to wash out the vagina once or 
twice a day with warm water^ to prevent any irritation from the 
offensive discharge. 

Variations in the period of the secretion of milk^ are of no 
moment ; if the vascular action be excessive^ it must be mode«> 
rated by antiphlogisfic remedies; such as tartar emetic^ fomen- 
tatioQSy &c., and by the frequent application of the child. If^ as 
in some very rare cases> no secretion should take place, fhe 
'child will require a wet nurse, but the mother will not sofibr. 

Many more variations from the ordinary course of conva- 
lescence after natural labour might be added, but I have been 
rather anxious to confine myself to those which are the most 
marked. I ana far from presuming to suppose, that these changes 
bave not been noticed by all who have seen much practice, but 
for the younger members of the profession these observations 
may not be altogether useless. I have expressly omitted the 
details of the management of the puerperal state, because, I cam 
refer the reader to Dr. Hamilton's work, where all I could say 
is stated more lucidly, and on far better authority. 



Art. V. — A Case of Disease of the Spino-occipital Articula- 
tion, with the Post Mortem Appearances. By Travers 
R. Blackley, M. R. C. S., &c. 

Mart Knm, aged eight years, was admitted March I7th, 1837, 
into the Hospital for Childreii, Portobella, for violent head- 
aches, to whidi she had been very subject for the last two 
months; these pains commenced suddenly on her return in (he 
evening from the funeral of her sister, to whom she was much 
attached. There was an appearance about (his patient which 
convinced me that the cephalalgia was to be attributed to the 
existence of some decided organic disease. 



Disease of the SpinO'OCcipital Articulation. 63 

Her countenance was peculiarly expressive of caution^ and waa 
florid^ and fiill^ if not bloated ; the chin was advanced preter- 
naturally beyond the chest, the mouth slightly opened, and she 
kept the arms parted from the sides as if to poise herself. On 
looking laterallyi she strained her eyes in the direction of the ob* 
jecty and failing in this, turned her entire body for the purpose. 
The effect produced when she attempted to observe anything 
placed near her feet was yet more remarkable ; for this purpose 
Aq generally put her hand to her forehead, as if fearful of un« 
due we^ht in the head, and bent her body, thus avoiding the 
least motion between the first and second vertebrae. In get- 
ting up from bed also, or in lying down, she invariably sup- 
ported the head with her hand. 

From a omsideration of these symptoms, I did not hesitate 
to attribute the disease to the cervical vertebrae. All the inferior 
cues appeaired sound ;* and when I took into consideration 
the very important motions performed by the atlas and second 
vertebra, which in thia case were extensively impaired, if not 
totally destroyed, and the organization necessary for the per- 
fefmanee of these motions, I at once referred the seat of her 
coaaplaint to these latter parts«t 

The headach was not permanent, sometimes she was free 
from pain for a couple of days;, especially while using the warm 
baCb, aid on those occasions exhibited a most dieerful dis- 
position ; aa the disease advattced, however, the intervals of rest 
w)Cffe fewer and of shorter duration ; the use of calomel seemed 
lo afford coBsidsraUe ease, until it slightly affected the mouth 
on the fifik day, from which time her sufferings appeared 
rather to be aggravated ; leechiBg and blistering, which had 



^^•^>mmmm 



* Sk€ exhibited no paiii whatevir on preisure over any part of the spinal co- 
lumn, even close to the occipul. 

t Two months before this child died, I ezpiessed my apprehension lest she 
should expire raddenly, upon her head being raised, as the transrerse Kgament 
might gWe wigp ; an aookliBt whicb oMwvsd tome yet» ago. at ths Bidunoad 
ifo^>ital« 



64 Mr. Blackley's Cme of 

been tried at the commencement of my treatment^ to the back 
of her neck, were perfectly useless, nor was the insertion of a 
seton in the same situation attended by any happier result 

The sufferings of this poor little creature were really most 
painful to witness, and at times amounted to agony ; on these 
occasions she always wished to have a bandage bound tightly 
round her forehead, or requested the nurse to squeeze her head 
between her hands, but the most effectual remedy was the 
tincture of opium in small quantities, repeated when necessary* 

Of late she referred the headach more to the left than the 
right side; the pain on several occasions left the head, and 
traversed the spine to the sacrum, from whence it return^ to 
its original seat ; she also complained occasionally of pain in her 
stomach, but this was always relieved by the application of a jar 
of hot water to the part ; the bowels were regular throughout. 

From the 14th of May she was unable to raise herself in 
bed, and her appetite completely failed, but at times she drank 
copiously ; she spoke very little, and her emaciation became 
extreme; during the last four days of her life the right arm was 
powerless, but slight grasping motions were observable in her 
fingers ; there was great lachrymation from the left eye, and it 
was doubtful whether she could distinguish objects with it. 
She expired without a struggle on the 29th June. Owing to 
the objections entertained by her friends to have the body ex- 
amined, I was obliged to content myself with the removal of 
the diseased portions, namely, the cervical portion of the ^Nne, 
and the portion of occipital bone in connexion with it; and 
with my friend Dr. Houston made a minute examination, the 
result of which was as follows : 

The articulating surfaces between the first and second ver- 
tebrae, and between the condyles of the atlas and occipital bone, 
were diseased, the cartilages eroded, the denuded bones gritty, 
and the capsules thickened and coated with lymph. The 
capsules of the loose articulations between the oblique processos 
of the atlas and dentata were particularly enlarged, and pro- 



Mr. Smith on Carcincmatous Disease. 65 

truded forwards under the deep muscles of the spine, forming 
three distinct abscesses pressing against the pharynx ; that on 
the right side had made its way downwards for more than an 
inch between the bones and muscles. The odontoid process 
was completely detached on all sides, and stripped of cartilage 
and synovial membrane, it was immersed in pus. The per- 
pendicular, oblique, and transverse ligaments had altogether 
disappeared, and the odontoid process was only separated from 
the spinal marrow by the thickened sheath of that organ. All 
the joints enumerated, including those of the odontoid process, 
appeared to be engaged in one suppurating surface. 

The fibrous sheath of the medulla oblongata, and commence- 
ment of the spinal marrow, were much thickened in texture, and 
the arachnoid and pia mater to the same extent were red 
and swollen, but the roots of the nerves were all perfect, and 
the medullary texture did not exhibit any organic lesion. The 
latter was perhaps a little softened, but had not undergone any 
alteration of colour ; I say a little softened, because, as Dr. 
Houston remarked, in the healthy state this part of the spinal 
marrow feels more resisting than any other, and in this instance 
it yielded most easily to pressure with the finger. 

The entire, which has been most carefully prepared by Dp. 
Houston, may now be seen in the Museum of the College of 
Surgeons. 

Art. VI. — History of a Case of Extensive Cardnonuztous 
Disease. By Robert W. Smith, A. M., M.R.I.A., Lec- 
turer on Surgery at the Richmond Hospital School of 
Medicine, &c. &c. 

Catherine Wakefield, set SO, admitted into the Richmond 
Hospital, March 2nd, 1837, under the care of Mr. Adams, 
labouring under carcimona of the lymphatic glands in the right 
axilla. About twelve months previous to her admission, she 
noticed in the above-mentioned situation a small tumour, hard, 
VOL. xn. NO. 34. K 



66 Mr. Smith on Carcinomatous Disease. 

moveable, and free from pain. A few months afterwards the 
right shoulder became swollen, painful, and tender to the touch : 
a number of small, hard, pale tubercles developed themselves 
in the integuments upon the right side of the chest and neck ; 
and the pain and swelling of the shoulder extended down the 
arm and forearm : her general health now declined, and her 
complexion became sallow. At the time of her admission into 
the hospital, the mammary gland did not appear to be impli- 
cated in the disease ; but the posterior wall of the axilla was 
occupied at its lower part by a tumour of stony hardness, irre- 
gular and knotty upon its surface, and extremely tender to tiie 
touch ; and the integuments of the axilla and shoulder, the 
right side of the chest and neck, were thickly studded with the 
small tubercles already mentioned. Shortly after the patient 
was admitted, however, the breast itself became engaged ; the 
entire gland became the seat of a hard, painful swelling : the 
nipple was not at any time much retracted ; but the skin around 
it presented numerous little hard grains or tubercles. At length 
the integuments over the tumour in the axilla became livid, and 
finally ulcerated. The arm was seized with exquisite pain, and 
became oedematous to such a' degree, that the pulse was not 
distinguishable in the radial, nor even in the brachial artery ; 
and towards the close of her life, the upper part of the arm be- 
came ecchymosed; large vesications containing a dark serum 
formed, and gangrene evidently impended. About a fortnight 
after the woman was admitted, she was attacked with symptoms 
of gastritis ; vomiting of green fluid ; tenderness of the epigas- 
trium ; desire for cold drinks, and inability to retain them for 
more than a few moments ; the tongue was red and dry*; the 
abdomen was slightly tender upon pressure ; the skin hot ; the 
feet cold ; the pulse 100, small and weak. Thb attack lasted 
for about a week, and was followed by a series of very anoma- 
lous symptoms. She ceased to complain of pain ; did not no- 
tice any thing that occurred about her ; in fact, consciousness 
appeared to have been lost ; die eyes were fixed ; the pupils 



Mr. Smltb on CarcmomcUous Disease, 67 

ioseosible to the stioiulus of light ; and^ as in catalepsy, the 
arm and hands would remain in any position in which they were 
placed. At this period of her illness, her bowels became ob- 
stinately constipated, and continued so for ten or twelve days ; 
at the end of which period, jaundice set in, and the alvine dis- 
charge presented tlie appearance usual in (hat disease. Shortly 
after the occurrence of the jaundice, she gradually sunk, and 
for a day or two before her death remained in a comatose con- 
dition. * 

The post mortem exatpination in this case, proved exceed- 
ingly interesting; inasmuch as it very satisfactorily explained the 
greater number of the symptoms. Upon opening the chest, the 
right lung was found closely adherent throughout its whole ex- 
tent to the side of the thorax : in every other respect the con- 
tents of that cavity were normal. Such, however, was not the 
case with regard to the abdominal and pelvic viscera : the peri- 
toneum was inflamed, and here and there lymph had been 
efiused. The ovaries (each of them nearly as large as an orange) 
were changed into a scirrhous structure of a yellowish white 
colour; they compre^ed the rectum to such a degree that the 
little finger could scarcely he^ passed through it The lining 
membrane of the intestine, below the compressed portion, was 
ioteosely vascular and inflamed : while above the ovarian tu- 
HMHirs, it was remarkably pde and covered ,with the peculiar 
clay-coloured feculent matter, usually present in jaundice. The 
glandB along the abdominal aorta were enlarged and indurated ; 
the gall bladder, distended with green bile, had passed down 
several inches below the edge of the Uver; the hepatic^ cystic, 
and upper portion of the common duct wei^ likewise greatly 
distended. The pancreas was slightly enlarged, and converted 
into a true scirrhous structure, in which tlie lobules of the gland 
could not be distinguished : the enlargement engaged chiefly its 
right extremity, which had surrounded and compressec^ the 
termination of the ductus communis to such a degree as to 
cause its almost total obliteration. The axillary and brachial 



68 Mr. Smith on Carcinomatous Disease* 

veins were dilated; and the blood was firmly coagulated in 
them throughout the greater part of their extent: both roots of 
the median nerve, where the brachial artery passed between 
them, were enlarged and indurated. The tumours thus formed 
were oblong, and about one inch and a half in length, and must 
have compressed the artery to a certain extent. The breast pre- 
sented the usual appearance of scirrhus of that organ, with the 
exception that the fibrous bands were not very well marked. 
The head was not examined, owing to what cause I dh not at 
present recollect. It is much to be regretted, as. in all proba- 
bility disease would have been found, and some explanation 
afforded of the nervous symptom mentioned in the history of 
the case. 

Notwithstanding, however, this deficiency, the case possesses 
interest in more than one respect. In the first place, it aflfords 
us an example of carcimona commencing in the axillary glands ; 
the breast being only secondarily engaged : and I am inclined 
to believe that such cases are more rapid in their progress, 
and more fatal in their termination, than those in which the 
lymphatic disease succeeds to that of the breast ; for the former 
case seems to indicate a more general contamination of the 
system, and is probably more frequently combined with visceral 
disease. At all events, in the case of Wakefield, no hope of 
recovery could have been entertained, even before the develop- 
ment of the disease in the mammary gland ; for the integuments 
were thickly studded with those hard, pale tubercles, which, 
when present, so uniformly denote the inveterate nature of car- 
cinoma. Operations undertaken in such cases are miserable 
in their consequences. I have seen them performed under such 
circumstances more than once ; but in every instance the disease 
returned before the wound was healed, and reached its fatal 
termination with frightful rapidity. To the intelligent surgeon, 
they are beacons, which warn him of the danger of interfer 
ing with the disease. The swelling, the great oedema, and 
threatened gangrene of the arm, are to be referred to the con- 



Mr. Smith on Carcinomatous Disease. 69 

dition of the glands and veins of the limb ; the structure of the 
former was completely altered, and the functions of both glands 
and veins destroyed : in feet, the circulation through the veins 
must have been arrested to a greater or less degree for a con- 
siderable time before death. I do not think that sufficient 
attention has been paid to the state of the circulation in these 
cases ; the veins should in every instance be examined, to ascer- 
tain whether or not, and how far they are concerned in pro- 
ducing the oedema of the arm, so commonly met with in cancer 
of the breast, and so uniformly referred to the obstruction of the 
lymphatic glands. In the case of Wakefield, even the arterial 
circulation must have been diminished, the artery being com- 
pressed by the diseased glands, and also by the tumours found 
upon each root of the median nerve. 

The obstinate constipation which this woman laboured under 
for many days was owing to two causes, either of which would 
have been adequate to the effect : first, the intestines were no 
longer stimulated by the influx of bile, owing to the compres- 
sion exercised upon the ductus communis choledochus by the 
pancreas; and secondly, the contracted rectum could scarcely per- 
mit the passage of fecal matter, so much was it compressed upon 
either side by the enlarged and scirrhous ovaries. The cause 
of the jaundice is obvious and of a purely mechanical nature; 
about an inch of the duct was completely imbedded in and sur- 
rounded by the indurated pancreas ; Anel's probe could not 
be passed through it without using force, and it required much 
time and patience to discover its opening into the duodenum. 
It is seldom we meet with disease of the pancreas ; we oft^i 
find, as Roche and Sanson observe, in the bodies of those who 
die of cancer of the stomach or liver, the pancreas surrounded 
by cancerous masses, developed in the surrounding cellular 
tissue, while the gland itself is almost always sound in the midst 
of this disorganization. Jobert mentions a case in which a tu- 
mour, developed in the pancreas, caused the almost total obli- 
teration of the duodenum ; and Mr. Todd has given the par- 



70 Mr. Smith on Carcinomatous 

ticulani of a case in which the pancreas was Bcirrboui. Tlie 
distended state of the gpdl bladder was remarkable in the case 
of Wakefield, but not so much so as I have seen in other leases. 
I have very frequently found it forming a tumour sensibly to 
manual examination ; and pnder such circumstances, it has been 
more than once mistaken for aa abscess and punctured. Andial 
has seen it distended tosiK^ a degree, as to touch the erest of 
the ileum, and even descend before it as far as the iliac {bssas : 
\mi the most remarkable case of the kind is, perhaps, that pub- 
lished by Mr. Todd in the first volume of the Dublin Hospital 
JReports ; the case is so interesting, and bears fK> much upon 
that of Wakefield, that I trust I shall be excused for aggiq 
bringing it before the profession ; the patient was a girl «^ 14. 
^^ At the time I saw the girl," says Mr. Todd, ^' h^r skin was 
of a deep orange colour ; she was greaUy emaciated ; had ana- 
aaroa of the lower extremities, and appeared to suffer much pain, 
although almost wholly insensible to external objects. She 
was unable to speak, and seemed not to understand any ques- 
tion put to her. Her hands were firmly closed ; her jaws fixed, 
ao that it was with difiiculty I could pour a teaspoouful of wine 
into her mouth. She moaned incessantly, and frequently scream*- 
ed, as if suddenly seized with acute pain. Upon examination, 
I discovered that the abdomen was distended with fluid, aa4 
that the epigastric and right hypochondriac regions were par- 
ticularly tumified ; a distinct, tense swelling occupied these re- 
gions, and could be traced extending even below the umbilicus. 
At one point, which appeared more prominent than the rest, a 
little below the ensiform cartilage, and to the right of the linen 
alba, a fluctuation was very evident This part was extremely 
sensible, as the least pressure on it appeared to increase Ae 
patient's suflferings; and I thought it very probable that alargf9 
abscess of die liver was here approaching the surface. With 
this impression, and anxious to aflford immediate relied^ I made 
an opening into the most prominent part of the tumour, by dis- 
secting cautiously with a lancet, and gave exit to a thin fluid. 



Mr. Smith on Cardnomataus Disease^ 71 

coloured with green bile. From the appearance of the fluid 
which escaped^ it immediately occurred to me that I had mis- 
taken an orer-distended gall bladder for an abscess, and having 
opened it, that its contents had mixed with and coloured the 
fluid effused into the abdomen. Wishing to prevent as much 
as possible the further extravasation of bile into the cavity, I 
introduced the canula of a trocar through the wound, which 
fortunately passed into the sac ; and the opinion which I had 
formed was then strengthened by my observing that the fluid 
discharged through the canula was viscid^ green bile, of which 
I drow off upwards of two quarts. Afler withdrawing the 
canula, a considerable quantity of the thin fluid was discharged, 
Mich as passed through the wound beforo the tube was intro- 
duced, artd the tumefaction of the abdomen entirely subsided. 
I then carefully examined every part of the abdomen, but could 
not discover enlargement of the liver, or any other swelling ; the 
patient, however, exhibited signs of augmented pain^ when pres- 
sure was made on the epigastric region. In the course of the 
day, the girl appeared in a flight degree relieved, and became 
more sensible ; but in the evening, all the un&vourable symp- 
toms returned ; the bdly became swollen, painful, and tense ; 
she bad several attacks of convul^ons during the nighL Next 
moming she was completely comatose ; her respiration labo- 
rious ; her pulse weak and intermitting ; and she died in the 
evenbg of diat day. 

^ On the following morning I examined the body. When the 
abdomen was opened, a large quantity of serous fluid, mixed 
with green bile, was discharged ; the peritoneum was inflamed 
in several part^, and flakes of coagulable lymph adhered to its 
surface, and floated ib the fluid. The liver was perfectly 
healthy* and of its natural size ; the gall bladder was empty, 
and contracted ; the hepatic and common ducts were enorfinously 
distended, and contabed more than a quart of bile, exactly 
similar to tbat which passed through the canula in the operation. 
7%e^e ducts formed a sac which extended from the porta 



72 .Mr. Smith on Carcinomatous Disease, 

of the liver to the os sacrum, lying behind the duodendum, 
pancreas, and root of the mesentery, and stretching in a trans- 
verse direction, so as to cover the anterior surface of the right 
kidney, and the greater part of the left. Having discovered 
and dilated the opening in the sac, which had been made with 
the lancet, I traced the distended duct up to the liver, where it 
received the smaller hepatic ducts, and these were so much en- 
larged, particularly that of the right lobe, as to admit of the in- 
troduction of one of my fingers without difficulty. The cystic 
duct, at its junction with the hepatic, was dilated for about half 
an inch ; but on examining the interior of it at this part, a sort 
of convolution or fold seemed to have been formed, whidi pro- 
bably acted as a valve, and prevented the bile from passing to 
the gall bladder ; the remaining portion of this duct was per- 
vious, and of its natural size. I next proceeded to search for 
the extremity of the common duct, which opens into the duo- 
denum, but could not discover it ; the pancreas was scirrhous, 
and that portion of the gland with which the ductus choledo- 
chus is connected, together with the surrounding cellular sub- 
stance, and absorbent glands, was converted into a hard, solid 
mass, closely adhering to the duodenum and lower part of the 
enlarged biliary duct, which last seemed to have been com- 
pletely obliterated. The pancreatic duct was also obliterated 
near to the intestine, and the biliary duct thickened, and its 
inner surface lined with a gritty deposit Such is the history 
of this remarkable case ; and it affords, as Mr. Todd remarks, 
a striking example of the power which some organs possess of 
accommodating themselves, both in their capacity and structure, 
to the force of distention when gradually applied to them. The 
history of another case, in which the gall bladder was punctured, 
has been published in the Dublin Hospital Reports, vol. v., and 
also in the Cyclopaedia of Practical Medicine, by Dr. Stokes, 
in the article upon Inflammation of the Liver, to which I would 
refer for some interesting remarks upon obstructions of the 
biliary ducts. 



Dr. Eck on Glanders in the Human Subject. 73 

Art. VII. — Contributions to the Pathology of Glanders in the 

Human Subject. By Dr. W. Eck. 

[Translated from the Bfedidnische Zeitoog for May, 1837, Not. 18 and 19.] 

That the introduction of contagious morbid products, derived 
from the lower animals, into the human system, is capable of pro- 
ducing much good and much evil, is universally known. The 
protective of vaccination, and the disastrous effects of inoculation 
with the hydrophobic vims, afford striking examples. The expe- 
rience of modem times has taught us, that many contagious 
diseases of the lower animals exercise a pernicious influence on 
man ;^of these I may mention mortification of the spleen and its 
consequences, the black pock (Schwarze Blatter), and glanders^ 
with its effects on man. 

The phenomena of glanders (a disease attributed to lym- 
phatic cachexy by Veith, and ranged among the tubercular 
afiections, as a specific degeneration of the cellular tissue, by 
Dupuy) in its acute or chronic form are well known, and have 
been graphically described in the official reports on contagious 
diseases. We are also well acquainted with the phenomena of 
button farcy, a disease which bears a close relationship to 
glanders, frequently conjoined with it, and generally arising 
from one and the same source, occurring only in the genus 
E^uos and its varieties, and distinguished chiefly from glanders 
by the affection of the cutaneous lymphatics, while in the latter 
disease those of the internal surface are engaged. It is likewise 
generally admitted, that glanders may become spontaneously 
developed in the horse by errors in the nutritive function, that 
is to say, under conditions which give rise to a morbid state of 
the lymphatic system, and particularly of those glands which 
have a more intimate organic connexion with the mucous mem- 
brane of the nostrils. Authors, however, are less generally 
agreed as to the power of infection which this disease possesses 
with respect to animals of the equine species. Even in the most 

VOL. xn. NO. 34. L 



74 Dr. Eck on Glanders in the Human SvbjecL 

modem times, it has been expressly denied by Godine, Dupiiy, 
and others. The inconvenience of many police regulations, 
founded on a conviction of the contagious nature of the disease, 
has favoured the partial introduction of the opposite opinion, 
which the uncertainty of the diagnosis in the first stage, and the 
fact, that a horse labouring under glanders, continues for such 
a length of time in the apparent enjoyment of general good 
health, has tended to corroborate. Again, where one horse 
labours under glanders, and a second or ^ third becomes 
affected, it is maintained, that each have been exposed to the 
influence of similar atmospheric or local causes; and where a 
horse exposed among a team of glandered horses, remains free 
from the disease, it is looked upon as a convincing proof of its 
non-contagious nature. On the other hand, the inoculation^ 
made by Viborg,* and his extensive experience of the destruc- 
tive consequences of the foregoing views, have difliised more 
widely the conviction of the contagious nature of glanders. 
Besides the reports of almost every provincial board of health, 
in modern times, have furnished cases of the kind ; and all our 
medical police councils have assumed as proven the contagious 
nature of glanders, a fact of which no experienced dealer in horses 
now entertains a doubt. And, though the fluid which flows from 
the nostrils is recognized as the chief source of infection; and 
that danger is chiefly to be apprehended from the use of utensils, 
mangers, and drinking vessels, &c. which have been in contact 
with glandered horses, and which are so likely to come in contact 
with the mucous membrane of the nostrils of sound horses ; 
still, we can scarcely doubt, that the contagion may not also 
exist in other excretions ; and that occasionally, as for instance, 
in close, damp stalls, sound horses may become affected without 
any contact, probably through the medium of the inspired air. 
That many horses are less susceptible of this disease ; that the 
intensity of the disease itself differs in degree ; that the matter 
of glanders loses its infectious properties by exposure to heat 



* (ibir Potz, Wurm uod Kropfder Pferde, in Seinen SammluDgeQ. Band. 2 and 3, 



Dr. Eck on Glanders in the Human Subject, 75 

and to fresh air; and that sound horses may remain for months in 
company with glandered without taking the disease^ provided a 
certain species of communication be prevented ; these are circum- 
stances which are analogous to those connected with other spe- 
cies of contagion^ and do not militate against the supposition of 
their infectious powers. With regard to infection, glanders and 
button farcy preserve an identity in the dyskrasy to which they 
owe their origin in this point also, — that the latter is produced 
not alone by inoculation with the purulent matter generated in 
the ulcers, but by inserting the matter which flows from the 
nostrils of a glandered horse into the skin of a sound one ; and 
vice versc^, glanders is produced by inoculating the mucous 
membrane of the nostrils with matter taken from an ulcerated 
spot of button farcy. 

The injurious and highly pernicious effects of glanders on 
the human subject is much less generally admitted. Up to a 
very recent period, only a few veterinary surgeons recognized 
tlie fact of its destructive properties in their published treatises, 
and even then, for the most part, with certain reservations. 
Thus, for instance. Professor Waldinger* says, " In dissecting 
horses who have died of glanders or button farcy, should the 
operator cut himself, great care must be taken not to let any 
pus get into the wound, as the most deplorable consequences, 
and even death itself, are to be apprehended." From this it 
appears that the only dangers he dreads, are connected with the 
opening of bodies, and from pus getting into a wound. Di- 
rector Veithf observes, ** The specific effects of the contagion of 
glanders act solely on animals of the horse species, and operate 
on other domestic animals chiefly as an acrimonious animal 
fluid. In man,| inoculation with the matter of glanders (which 
generally occurs from a cut finger coming in contact with the 
matter, or from the matter getting into the eye when the animal 



-r*- 



* Waroehmungen an Pferden. 2te* Aufl. Wien, 1810. p. 95. 
t Htodbuch der Veterinairkunde, 2te. Aufl. 1822, S. 685. 



76 Dr. Eck on Glanders in the Human Subject, 

suddenly and forcibly expels it from the nostrils,) brings on 
violent inflammation of the parts^ which is extremely painful and 
obstinate, involves by sympathy the neighbouring lymphatic 
glands, and bears a resemblance to the arthritic inflammations." 
From tliis it would seem that Professor Veith was merely ac- 
quainted with the injurious local effect of the poison on man. 
The late director of the veterinary school in this city. Professor 
Naumann, and Veterinary Surgeon Hallbach/ when asked their 
opinion as to the infectious power of glanders with respect to 
the human subject, in a suspicious case, which was under the 
care of Dr. Schilling in 1821, stated, ^^ that they had not met 
with any example of the disease in man, from glandered matter 
received from a living horse, and that none of the veterinary 
surgeons or grooms who had been occupied with living or dead 
glandered horses, had ever been infected. On the other hand, 
however, there were not wanting instances in which persons who 
had cut themselves, while making preparations from such bodies, 
occasionally had bad forms of inflammation, and even mortifica- 
tion affecting the hands and forearms." About the same time 
also Veterinary Surgeon Major Dietrichsf disputed the possi- 
bility of the human subject taking infection from a living horse, 
but admitted that he had met with some cases, in which men 
who cut themselves while dissectiiTg the bodies of horses who 
died of marasmus and glanders, became ill, and got mortifica- 
tion of the injured part, which proved fatal. Nay, Surgeon 
Hallbach was so little afraid of infection from living horses, that 
he offered to inoculate himself with the matter of glanders. 

The fact of the existence of such opinions among expe- 
rienced veterinary surgeons, the few opportunities which most 
practitioners have of observing the disease in man, the ignorance 
of its symptoms among former observers, and the false repre- 
sentations which have been given of cases, will be sufficient to 
explain the prevalence of the foregoing views among the majo- 



* Rust's Magazib, B. xi. S. 500. t Rust's Magaziu, B. xi. S. 510. 



Dr. Kck on Olanders in the Human Subfect. 77 

rity of medical men ; and hence I have not been much surprised 
to hear, not long since, from medical functionaries, and practi- 
cal physicians of the first class, similar opinions as to the un- 
proved, or at least hypothetic and improbable noxious qualities 
of glanders with respect to man. Since 1821, however, a dif- 
ferent opinion has prevailed, founded on the experience of hos« 
pital, military, provincial, and veterinary surgeons, and has been 
communicated to the public in offidal reports, dissertations, and 
widely circulated journals. Among these I may mention the 
interesting case of an artillery man, named Rennspiess, detailed 
by Dr. Schilling in November, 1821.* 

In this case there was no direct certainty of infection from 
glanders ; but it was extremely probable, as the man had been 
attending and grooming some glandered horses, and stated that 
he bad frequently washed the ulcerated nostrils of these animals. 
In the same month, the case of a groom, named Elliech, oc- 
curred, and was communicated to the medical council of Silesia 
by Dr. Weiss, the district surgeon of Neumarkt.t In 1822, 
an interesting description was given by Tarozzi of a pestilential 
disease which appeared, about the beginning of 1815, among 
several men in a stable at Ostiano, whero there were glandered 
horses, and at a time when there was no trace of any such disease 
in the vicinity4 To these may be added the experience of 
Schrader,|| Travers,§ Numann,f Elliotson,** and Williams ;tt 
Brera's treatise on Carbuncular Typhus, produced by Glan- 
ders 4t ^he series of accurately detailed cases given by Profes* 



* Rust's Magazio, B. zi. S. 480. 

t Rost's Magazio, B. xi. s. 480. Hufeland*s Journal for March, 1822. 

t Omodei*s AoDals for 1822. || Hamburg Magazin for Jan. and Feb. 1823. 

§ Inquiry into Constitutional Irritation. 

^ Vee-artsenykund Magazin. Deel ii. St. 2. 

*' Medico-Chirurg. Trans, vol. zvi. p. 171. 

f f Medical and Surgical Journal, No. LVII. p. 156. 

it Anthologia Medica for Sep. and Oct 1834. 



78 Dr. EdL on Glanders in the Human Suljeet 

4or Hertwig* and -my colleague Worlff if the inaugoral disaerr 
tions published on this subject at Berlin by GrubJ^ Krieg^U 
and Barth;g as also two remarkable cases communioated by 
Professor Alexander^ director of the Hospital of Instruction at 
Utrecht, and accompanied by .an accurate detail of the post 
mortem pb^omena* I may also state^ that my friepd Bemdt 
has defoted a particular seelion to this subject in his admirabk 
work on pathology and therapeutics. 

After adducing 80 many instances^ drawn from the stores of 
modem observation^ and confirmed by practitionors of various 
countries, the attempt to render conviction stronger may appear 
sup^'fluous; But when, even in 1832, we find Parent Du Cha- 
lelet, in a report made to the Academy at Paris, maintain, th&t 
^ none of the supposed infectious diseases of animals exercised 
an unfavourable influence on the health of man ;" when further, 
ia ja widely perused journal published in this t^ity^lf we find a 
practical physician. Dr. KrQger Hansen, in examining WolfiTs 
proposition above mentioned, denying the existence of infection 
from glanders in general, and its pernicious effect on man in 
particular; and in pretty plain terms attributing all the bad 
consequences which arise from such infection to inaccurate diag- 
nosis and bad practice; finally, when we perpend the troth 
^od. importance of .Goethe's words^ ^^ that the truth must be 
constantly repeated, because error is preached upon every 
«de, not only by individuals, but also by the mass of man- 
kind/', it J)ecomes our duty not to hold back any communi- 
cation^ however trifling, calculated to banish a pernicious con- 

* MwIicidUhe Zeitung Jahrg. 3, Nos. 46 and 47. 

f Med. ZeituDg Jahrg. 4, Nos. 1 and 2. 

t Diss, sistens casum singularem morbi contagio mallei humidi in horoiDen 
translato orti, 1829. 

II De Typho Malioide, 1829. 

§ De nonnulHs epidemiis et epizootiis umul regnantibus, earumque mutua 
indole contagiosa, 1835. 

f Grafe and Walther's Journal, Band 23. Heft 1. s. 58. 



Dr. Elck on Glanders in the Human Subject. 79 

fidence, and to contribute to the knowledge and treatment of 
an animal pou(pn, which though seldom observed^ still when it 
once occurs, whether openly or in a latent form, threatens the 
most alarming consequences to human life. These considera- 
tions have induced me to publish the following seven cases of 
disease, consequent on actual or supposed infection from glan*- 
ders. These have been derived partly from my own experience 
and partly from that of my colleagues. 

Cass. L — The case observed by myself, the true natureof which 
I only began to suspect towards the end of the disease, and whicli 
I had afterwards an opportunity of verifying, occurred in 1830. 
On the afternoon of the tenth of July, lanoe-corporalJ. Rudor^ 
of the Dragoon Guards, aged 25, five and a half years in tho 
service, and by profession a saddler, was admitted into the regir 
mental hospital About a month previously, that is from the 
20th of May to the dth of June, he had laboured under ague, 
but had never been ill before during the whole period of his 
service. Some days before his last admission he had com«- 
fdained of agonizing pains in the upper and lower extremities, 
heaviness of the limbs, and sense of weight in the head, which 
subsequently changed to a most intolerable headach, so as to 
force tears from his eyes. When admitted, he complained 
diiefly of torturing pains in the limbs, and weight of head. 
His face was red ; skin hot and dry ; his thirst great ; pulse 
hard, full, waA frequent The disease was looked upon as inflam- 
matory feven (in the book I find it designated, at first, as acute 
rhenmatiam,) and he was ordered to be blooded, and to have a 
cooling mixture, first of glauber salts, and afterwards of nitre, 
with lemonade for drink. The blood exhibited a firm coat of 
buff, and tlie violence of the headach, as well as the hardness of 
fte pulse, diminished remarkably after his bowels had been 
freely opened ; but the pains in the limbs, and the frequency of 
pulse, continued. On the I2th, tumours like boils formed on the 
outside ofthe left knee and on the right tibia ; these gradually in- 
creased in size, passed deep among the musdes, and seemed to 



1 



80 Dr. Eck on Olanden in the Human Subjeot. 

contain a fluid. They presented no inflammatory appearance ex- 
ternally^ or at most a pale blush, but they were eicessively pain- 
ful on motion, and communicated a burning sensation to tiie 
touch. On the 13th, the congestion of the head again returned ; 
the patient was sleepless, and occasionally delirious ; the pulse 
100 in a minute ; the skin dry and burning ; the face red ; thirst 
urgent ; tongue dry and loaded. Eight ounces of blood were 
again drawn ; and the patient took calomel, at first three grains, 
and afterwards a grain every two hours. The relief, however, 
was but of short duration. From the l4th to the I5th the fever 
increased ; the head became remarkably affected ; there was 
strong pulsation of the carotids ; delirium more constant ; and 
during its brief intermissions, the patient complained chiefly of 
violent pains in the legs and head. Twelve leeches were applied 
to the temples, mercurial frictions were made in the vicinity of 
the tumours, and the knee was enveloped in tow, but without 
any benefit ; the fever increased, assumed more of the nervous 
type ; the manifestations of consciousness became fewer, and 
tumours of the same kind began to appear on the thighs ; the 
skin became dry, rough, and hot, particularly in the neighbour- 
hood of the tumours ; the tongue parched, chapped, and 
covered posteriorly with a dirty brown fur. The foregoing 
plan of treatment was abandoned, and an attempt vras made to 
act on the skin by carbonate of ammonia, infiision of elder flowers, 
and baths; and the painful swellings were bathed with a decoc- 
tion of chamomile flowers, containing acetate of lead, and tine- 
ture of opium. The patient perspired copiously, and had some 
sleep after the bath ; but there was no improvement in his 
symptoms. Tumours began to appear on the left knee, the 
right thigh, the left forearm, the neck, and the left upper 
eyelid, partly of the foregoing description, partly livid, round, 
some filled with pus, others hard to the touch, of various 
sizes, and all extremely tender. The day before the], patient 
dieid, I stated, on visiting him, that his whole disease had 
been of a peculiar character, and that he must have laboured 



Dn Eck on Oldmters in the Human Subfed^ 81 

under the infliienoe of some specific poison. Whereupon, a 
patient of the same squadron, who had been admitted during hid 
illness, observed, when questioned as to the patiqpt's mode of life 
ktl^ly, that he had been occupied for a long time in the sick 
horse stable. The matter was now cleared up at once ; atad 
I immediatdy recollected the effects of the poison of glanders 
of which I had read much, but unfortunately, as generally hap- 
pens to those who have not seen them, had not thou^t of 
before. The patient's condition in the mean time b66ame still 
more putrid; his pulse small, frequent, 125 in a minute ; his 
fiK^e rather pale than red ; his skin dry and hot : he remained 
almost constantly in a state of unconsciousness and low delirium, 
and passed involuntarily quantities of abominable faeces, smell- 
ing like carrion. A warm alkaline bath, and cold effuuon, 
roused him for a moment ; he then sank with all the appear- 
ances of profound collapse, paralytic dysphagia, sopor, cold per- 
spirations, and finally spasmodic contractions of the muscles of 
the bee. He died on the 18th of July, at nine o'clock in the 
evening. 

Od opening the body, the pale red boils and the lirid pus- 
tules were found considerably collapsed ; the latter were partly 
^filled with yellow thick pus, the former with an offensive fluid 
of a chocolate colour, which was also infiltrated among the 
muscles, and bad made its way down even to the bones at 
certain points. The muscles were in general sound, but some 
spots appeared pale and softened. The venous blood had a 
remarkably watery appearance, was diMoloured, and appeared 
as if mrsed with a slimy fluid, as far as the rfght auricle ; the 
crural vein of the right side was very much distended, and its 
blood seemed to be mixed with a mucous or puriform fluid ; 
the internal coat of the vein was of an ash gray colour at various 
spots, and covered with a puriform exudation. This part of the 
disseoti<m appeared to me peculiarly interesting, on bringing to 
mind the description of the state of th6 veins in Czama Krosta, 
(pustola maligna,) which I had read in the Dorpat Clinical An- 

VOL. XII. NO. 34. M 



83 Dr. Eck an Olanders m the Itunmn SubjeH. 

nals. There was no trace of itiflammation in the cavities of the 
brain; the superficial veins contained a larger quantity than 
usual of dark fluid blood ; a spot on the centre of the posterior 
lobe presented some superficial ramoUisseuient ; on the right 
side there was a superficial abscess about the si^ of a two gros- 
chen piece, and about one-eighth of an inch in depths containing 
matter similar to that found in the pustules. The lungs were 
normal ; the pericardium contained about two ounces of dark 
brown fluid ; the liver was softer than natural^ the bile of a clear 
yellow colour. 

After the fatal termination of this case, my first inquiry Was 
directed to the disease of the horses which the patient had at- 
tended. At that time^ however, I could not obtain any accurate 
information. It was stated that some of the horses had glan- 
dular affections, and disease resembling glanders. I afterwards 
inquired from the Serjeant of the troop, and learned from him, 
that both the horses which Rudorff had groomed were killed 
in consequence of being glandered ; one on the 1st, and the 
other on the 25th of October, 1830. How he had received the 
infection, it is diflScult to say ; but a dragoon stated to me, that 
he was in the habit of keeping his bread in the manger. It is 
also probable, that Rudorff*, who was a saddler by trade, might 
have had a wound on his hand or some other part of his body. 

Casb II. — The following case was observed and puUished 
in the official medical report for the province of Brandenbai^ 
in 1834, by my colleague. Dr. Grossheim, of this city. A mi- 
litary pupil of the veterinary school, named Lork, although not 
specially engaged in the care of diseased horses, had been in 
frequent contact with glandered horses while making eitaminft' 
tions. Whether he had a slight injury on one of his fingers, or 
not, is not certain ; at any rate, it must have been very slight, 
for he expressed himself doubtfully on the point, and merely 
said that such might have existed. The first inconvenience 
which he felt> consisted in a painful sensation in the fingers, 
without any evident tumefaction, but accompanied by fever, and 



Dr. Eek on Glanders in the Unman Subject. 83 

extending soon after to other parts of the body^ particularly the 
joints of the upper and lower extremities^ so as to simulate fly- 
ing rheumatic pains. He was admitted into the general mili- 
tary hospital on the 3rd of February, and when examined, pre- 
sented slight tumefactions over the right ankle and knee joint, 
both elbows, and some of the joints of the fingers ; these, how- 
ever, were so ^ght, that they only appeared evident when 
compared with the corresponding parts on the opposite side. 
The accompanying fever was of an inflammatory character ; the 
pulse was full and rapid, the thirst extreme, his eyes shining, 
his respiration oppressed and difficult, great prostration, loss of 
appetite, nausea, loaded tongue, and constipation. With the 
view of moderating his fever^ he was blooded, and took glauber 
salts followed by an enema ; he then took infusion of elder 
flowers with antimonial wine and spirit of mindererus, with the 
view of acting on the skin. He perspired copiously, but with- 
out any diminution of the fever ; and the agonising pains be- 
came more generally diffused, so that scarcely any part of his 
body escaped. To relieve the gastric symptoms, he took the 
compoQud infusion of senna and an emetic, but without any be- 
neflt. 

From the 12th of February, several circumscribed doughy 
swellings, without any superficial redness, began to form deeply 
under the cutis, on the arms, legs, and head. During this pe- 
riod his breathing was very much oppressed, so that it was 
tiiought necessary to bleed him : he afterwards took calomel in 
combination with camphor and opium, and vapour baths, which 
had the eflect of producing a temporary alleviation of his pains. 
He was then attacked with diarrhoea, followed by remarkable 
prostration ; and his disease began to assume the character of 
nervous fever, attended with great congestion of the brain. He 
had delirium, alternating with consciousness, heat of scalp, suf- 
fusion of the eyes, dry tongue, small and rapid pulse. Some of 
the furuncolar tumours were extremely painful, particularly one 
about the size of half « hazel nut, situated over the left parietal 



84 Dr. Eck (m Olanders in the Human Subfeet. 

bone. On the surface of the latter several minute openings 
formed, from which a brov?nidi puriform fluid exuded. A num- 
ber of miliary vesicles made their appearance on his face^ 

The treatment, which was regulated by the symptoms, con- 
sisted in giving mineral acids, Dover's powder, nitre with cam* 
phor, calomel and digitalis, and the application of leeches to 
the forehead and temples, with cold affusions. The patient 
died on the night of the 4th of March, with the usual symptoms 
of typhus in the last stage, as sopor, muttering delirium, sinking 
of the countenance, involuntary discharge of urine, &c. The 
evening before his death he had copious general perspiration. 

On dissection, the vessels of the dura and pia mater were 
found greatly congested, as also the substance of the brain, and 
the choroid plexus : there was a sero-sanguinolent effiiaon in 
the cavities of the brain and spinal cord. A similar efiusion 
was discovered in the pericardium and both pleural cavities ; 
and on the left pleura costalis there was a quantity of extrava- 
sated lymph. On cutting into the liver, a large quantity of 
bloody serum gushed forth ; the vessels of the stomach and 
upper part of the small intestine were strongly inject^, and the 
larger arterial branches presented at certain spots a remarkably 
red colour. Oblong suppurating tumours, about the aiae of 
half a walnut, and containing a more or less brownish fluid, of 
tolerable consistence, were found in many parts of the muscular 
substance of tiie upper and lower extremities, viz. in the belly 
of the extensor digttorum communis, brachialis intemus, nipi- 
nator longus, and gracilis, of the right side ; also in the brachia- 
lis intemus, and peroneus longus of the left side : these tumours 
were covered by the aponeurotic extensions. The neighbouring, 
and in particular the subjacent muscles, were wasted ; but there 
was no trace of inflammation or vascular congestion. 

Case III. — I am indebted to Physician General Dr. Loh- 
meyer, for the following case, extracted from the Army Medical 
Reports. A soldier of the Ist Hulan Regiment, aged 23, oom- 
{dained on the 2nd of July, 1834, of pain in the right index 



Dr. Eok OH Olandersin the Human Subject. 85 

finger^ arising from a slight injury of the skin^ the cause of 
which the patient could not exactly state. Although the in- 
jury seemed trifling and inconsiderable, the whole hand was 
inflamed and swollen, and the swelling and inflammation be^ 
came more extensive under the use of warm, soothing applica- 
tions ; painful inflammatory boils appeared on the hand, fore- 
arm, and elbow joint, and the axillary glands became swelled 
and tender. He then got feverish, and was admitted into the 
hospital on the 6th July, where the warm applications were 
continued, and frictions with mercurial ointment employed*. 
Up to the 12th the swelling of the axillary glands diminished, 
but the boils on the forearm and hand suppurated, and were 
opened. At the same time the injured spot on the index 
finger increased in size, its edges became tumid, its surface 
foul, and it discharged^ a fetid, greenish yellow pus. It was 
powdered with the red oxyde of mercury, and covered with 
simple dressing. It was now ascertained, that the patient had 
for several weeks been attending two horses labouring under 
glanders, and which had been subsequently killed, on that ac- 
count Although the feverish symptoms had almost entirely 
disappeared, and the patient did not feel ill, inflammations and 
swellings appeared from time to time on various parts of his 
body. He took acids, decoction of bark with muriatic acid, 
and the ulcers were dressed with turpentine and tincture of 
myrrh ; under this treatment the boils improved. On the 26th 
of July, a painful erysipelatous inflammation appeared on th^ 
left ankle, and two days afterwards another of the same kind 
on the right wrist. Feverish symptoms set in, and the patient, 
who had hitherto been walking about the ward, felt so weak as 
not to be able to leave his bed. Dry applications, and sub- 
sequently, when the pain and inflammation increased, leeches 
were employed, but without relief; warm poultices and decoction 
of bark reduced the swelling ; but instead of the pain felt before, 
he had now a numbness in the afiected parts, with loss of power 
in the limbs, and increase of fever and emaciation. Up to the 



86 Dr. Eck an Okmders in the Human Subject, 

12th of August; the fever had assumed a low type, which be^ 
came gradually more developed ; new swellings of the fore- 
going description, and with a doughy feel, formed, and when 
they disappeared, were replaced by fresh ones on other parts 
of the body ; none of these, however, exhibited marks of 
fluctuation. 

Infusion of valerian and sulf^uric acid were added to his 
drink, but the fever and weakness increased, delirium set in, 
and a number of small boik, raised on a hard inflammatory 
base, formed on his face, neck, and breast; these were about 
the size of a silver groschen, and presented on their surface 
purulent vesicles, which broke and discharged a fetid, bloody 
sanies.. The delirium and oppression increased up to the 17th 
of August, when the patient died, having remained six weeks 
and three days in hospital. 

Case IV. — The following case, witnessed by Surgeon Krat^ 
censtein of Stralsund, and attended with &tal effusion of pus 
into several joints, is taken from the Reports of the Board of 
Health for the Province of Pomerania, published in 1835. A 
labourer, aged 46, of delicate constitution, and who bad 
suff^^ much froip illness during his childhood, but had sub^ 
sequently epjoyed good health, with the exception of an attack 
of scabies about ten or twelve years previously, received a 
trifling injury of the little fin^r of the ri^t hand from a nail, 
while gadiering'up some provender which had remained in the 
manger after a strange horse. He took no notice of the in^ 
jury, and continued to discharge his usual oflSoes until the fourdi 
day, when he felt so unwell as to be obliged to remain athooM. 
On the eighth day after the receipt of the injury he sought for 
medical advice^ He had at this time violent fever, with se- 
vere gastric symptom^, the right hand was gready swelled and 
4here was an erysipelatous blush over the little finger, and the 
wiist joint At both these spots, a slight fluctuation indici^ed 
the formation of matter. He took carbonate of ammonia, an 
emetic, and aperients; aad the parts were sprinkled with flour 



Dr. Eck on danders in the Human Subject. - 87 

but without any benefit. As soon as fluctuation shewed that 
pus was formed, the abscesses were opened by a longitudinal 
meision, and a considerable quantity of healthy pus discharged. 
A few days afterwards red^ painful spots, about the size of a 
dollar, and slightly swdlen, appeared on the wrist and elbow 
joints of the left arm ; the latter was opened by a free incision^ 
as it exhibited proofs of the formation of matter, and a quantity 
of pus discharged. Both feet were swollen/ but without any 
redness or marks of suppuratbn. The fever continued with 
decrease of strength^ delirium, and copious suppuration, thb 
matter becoming of a more unfkvourable character. Bark, 
acids, wine, broths ; the local application of warm arontiatic 
dressings, and enlargement of the openings into the abscesees, 
proved ineffectual. The right wrist joint was first attacked 
with suppuration ; in spite of bandages and splints, spontaneous 
dislocation took place, the ends of the bones were denuded of 
periosteum, so that at each movement a grating was felt in the 
metacarpal bones and phalanges. Suppuration also took place 
in the right ankle, imd notwithstanding the same applications 
were made, the ligaments became loose, and all the bones of 
the foot seemed capable of free motion. The man died afler 
eight weeks spent in great agony. Dr. Rhades, the compiler 
of the Provincial Report alluded to, seems to think it was very 
probable that this peculiar malignant disease arose from the 
contagion of glanders, although he had not been able to find 
out anything concerning the horses which had been in the 
stable where the patient was supposed to have received the 
mfbction. 

Casb V. — The following interesting communication appears 
among the reports of the Board of Health for the district of 
Marienwerder, as detailed by District Surgeon Genzmer : — " A 
groom named Knobe, aged 27, became ill about the beginning 
of the month of November, 1835* He had been attending 
glabdered horses for two months previous to this period. He 
complained at first of dislike of business, languor^ loathing of 



88 Dr. Eok on Glanders in the Human Subject. 

food amounting to nausea^ and constant tendency to Tomit I 
ordered him an emetic, which was followed by a copious dis- 
charge of mucus and bile with great relief of his symptoms. 
The following days he complained of pain in his chest, and in 
all his limbs, but particularly of an affection of the head. At 
night he became quite feverish, but towards morning had 
copious perspirations, with remission of his sjrmptoms. He was 
ordered to take carbonate of ammonia, and nitrate of potash. 
On the fifth day, he complained of pains in the right arm, and 
in the right and left forearm, as also in the right leg, im- 
mediately over the ankle. On examining these parts, I found 
at the painful spots cold tumours, partly of an oblong, partly of 
a roundish form, having a doughy feel, but without any al- 
teration in the colour of the skin ; the fluctuation of fluid could 
be felt in them. They were rubbed with mercurial ointment 
and camphor, lliese measures having effected no change, 
the boils were all dressed with the emplastrum foetidum, and 
an infusion of arnica with carbonate of ammonia was given in- 
ternally. The fever now became exacerbated at night, and thfe 
morning perspirations were extremely profuse, attended with a 
remission of the symptoms. A higher degree of vital ac^vity 
b<^an now to manifest itself in the tumours ; they inflamed and 
burst after using the remedies above mentioned for the space of 
four days, giving exit to a darkened sanies ; they were then 
dressed with stimulating applications. The patient now began 
to improve, and was ordered to take light tonics, but the doers 
still had an indolent appearance, and formed deep suppurating 
cavities. An ointment composed of iodine, and unguentum 
eleroi, was ordered for dressing, and the patient took iodine 
made into pills with extract of acorus calamus. This was 
followed by an improvement in the condition of the ulcers, they 
assumed a more favourable appearance, began to discharge a 
more healthy pus, and at present (March, 1836) they are 
nearly well. The patient is improved in s^^igth, and it is 



Dr. Eek on Glanders in the Human Subfect. 89 

expected that he will be quite restored to health in two months 
at farthest" 

Case VI. — '' John Kaletzki^ a groom^ aged 34^ was ap- 
pointed to fill the place of Enobe^ when the latter became 
miwell, a task which he performed much against his inclination. 
After having discharged this duty for about six weeks^ he was 
attacked on the 6th of January^ 1836^ in the same manner as his 
predecessor^ except that the pneumonic symptoms were more 
violent, and threatened suffocation. Ho was bled with relief, 
and the blood exhibited a slight coat of buff. On the third 
day the pulmonary symptoms returned, leeches and a blister 
were applied, and relief again obtained ; internally the patient 
took a cooling mixture of nitrate of potash. Four days*after- 
wards, cold but painful swellings appeared on the clavicles, 
and subsequently on the left arm, and on both thighs. The 
tumours had the same appearance as those observed in Knobe, 
but Koletzski complained of more pain, and his fever was much 
greater, and had more of the asthenic character, so that the ni- 
trate of potash was changed for carbonate of ammonia. The 
patient then complained of pain in the throat and difficulty of 
swallowing, but there was no appearance of injury in the inte- 
rior parts of the mouth. On the 18th, Dr. Burkhardt saw the 
patient with me, and recommended a solution of oxymuriate of 
mercury in full doses, which was administeredffor some days. 
The fever, however, increased daily, delirium prevailed, parti- 
cularly at night, and the patient had copious alvine evacuations 
of a putrid, offensive character, attended with evident sinking of 
the powers of life. He now took infusion of valerian with mu- 
riatic acid, and subsequently infusion of arnica ; mercurial oint- 
ment with iodine was rubbed over the tumours, but without al- 
teration in their appearance or character. The difficulty of 
swallowing increased, so that the patient was unable to swallow 
a qxxmful of medicine ; and as there was no apparent alteration, 
it was inferred that this arose from paralysis of the oesophagus. 

VOL. xn. NO. 34. N 



90 Dr. £ck on Glanders in the Hummn Su^eeL 

The patient died with alt die symptoms^of general collapse and 
exhaustion^ on the 5th of February." 

Case VIT. — Dr. Grimfli of Kempen, details the following 
case as ohs^vedby him, and published in the official Medical Re- 
port for the District of Posen. A healthy man,aged 23, residing at 
Kenpen^ who had the care of a glandered horse, after a slight 
«aper(icial injury of the right index finger, got a violent inflam- 
matory swelling, which soon extended over the whole hand, 
became extremely painful, and in a few days increased so much, 
in extent as to comprehend the whole forearm as far as the 
elbow. Some glands about the elbow, and afterwards those of 
the axHIa, became swollen and painful, accompanied by feverish 
excitement of the pulse. Dr. Grimm ordered soft poultices 
and flrictions with mercurial ointment ; the wound on the finger, 
which presented a foul appearance, with tumid edges, and 
greenish, foetid discharge, was dressed with red precipitate. 
Constipation was removed by the use of calomel, and the pa- 
tieat took muriatic acid with decoction of bark, and acidulated 
drinks. The swelling of the axillary glands diminished under 
this treatment ; but boils of different sizes, and of a purplish 
hue, formed on the arms and varbus other parts of the body, 
pnesented marks of fluctuation, and when opcoied discharged a 
titin whitish pus. The fever increased, the patientilost strmgtii, 
and the limbs became useless from the number of tumours pre- 
venting motion, so that he wasobligcKl to remain in the horizon- 
tal, posture ; one in particular appeared on the left ankle joinl;,, 
attended with severe pain^ Eight leeches were applied without 
benefi)t» but he was aomewhait cdieved by warm poultices Hfe 
also took bark, but without, any im.p9ovement in his symptoms. 
The tumours increased in number, but no. longer presented- 
marks of fluctuation ; he suffen^ greatly from constcictaoa of 
the dbest, with delirium, and all the symptonas of typhoid &ver. 
A number of small boils, about the size of a ^lit pea^ with 
hard^ inflamed bases, appeared on his face, ned(, and braast; 



Dr. £ck on Olanders in the Human Subject. 91 

on the centre of tbese^ transparent veBictes formed, which 
burst, and discharged a foetid brown sanies* The patient died 
on the fortieth day of his illness. No aatopsy was allowed. 

The foregoing cases, analogous in their results, and ad- 
mitting in general of being placed in the same class, will serve 
at least to add to the repeated proofs, that glanders is un- 
doubtedly a poison, and one of a very pernicious kind toman. 
That its effects on man are different from those observed in the 
horse and ass, is by no means surprising ; the same thing occurs 
in the case of mortification of the spleen and hydrophobia. Is not 
die peculiar symptom which has given its name to man, want* 
ing in tlie dog ? Again, it is not so very strange, that the phe* 
nomena of infection from glanders, should be different in dif* 
ferent individuals of the human species, even though we should 
meet with a greater variety of shades than is recognised by ex* 
perience. Is it not the case with other diseases of contagious 
origin ? Do not syphilis and many other diseases appear un- 
der a variety of forms? and are not the forms of glanders and 
button farcy different, according to the difference in their mode 
of origin, and of the tissue in which they form ? If the symp- 
toms detailed by tlie foregoing authors differ a little in some 
points, is not the mark of acute rheumatism with which the 
disease generally commences in man, the fever at first seemingly 
sthenic, but attended with great frequency of pulse and weak* 
ness, and passing rapidly into asthenic nervous fever ; are not 
the formation of boils and abscesses, which correspond with the 
button farcy of the horse, as well as the whole posi mortem 
phenomena highly characteristic? Finally, that in one case, 
no infection arises from intimate communication with diseased 
animals, while in others the most fatal consequences arise from 
alight intercourse ; that the disease assumes one time the form 
of acute or chronic glanders, and at another time more of but- 
ton farcy ; that occasionally it exhibits some resemblance to 
malignant pustule ; that in some cases it is rapid, in others 
creeping ; that it sometimes terminates in recovery, and at other 



92 Dr. Eck on Glanders in the Human Subject. 

times in death. All these are circumstancs which may depend^ 
Ist, on the difference of form of the glanders or button farcy, 
which may be most dangerous to mankind in its acute form ; 
2ndly^ on the peculiar stage of this form, and the difference in 
the intensity of the contagion connected therewith ; 3rdly, on' 
the difierence of the surface on which the contagion is received, 
whether it be a wound or ulcer, or the mucous membrane of the 
nostrils, the conjunctiva, or a part of the skin covered with de- 
licate epidermis, as the lips ; or whether the infection has been 
communicated by the breath of glandered horses, and has en- 
tered the system through the lungs ; 4thly, as in all contagious 
diseases, we must take into account the susceptibility of the in- 
dividual, which may have been increased by some previous 
disease. We find, in small-pox, that after exposure to the same 
contagion, one person will have variola, another varioloid, and a 
third varicella, according to the different individual suscepti- 
bility of each. 

Weighing those various circumstances, I cannot agree with 
the opinion expressed by some individuals, that the case c^ 
Rudorff was not one of glanders, but was produced by some 
other animal poison. On the contrary, I am inclined to think 
the severe form of disease observed in him, arose from the re- 
ception of glandered matter of a very bad character, probably 
on the mucous membrane of the nostrils, and while a great sus« 
ceptibility to the poison existed. I am the more inclined to 
adopt this opinion, as the disease in this man exhibited many 
traits identical, not only with glanders in the horse, but also 
with (Ustinct cases of the disease in man. In the character of 
the symptoms noticed in this case, there is a certain gradation 
easily recognized, from tlie purely local form, (as observed by 
Schrader, in a veterinary surgeon who scratched his finger with 
the nasal bone of a glandered horse,) to the form attended with 
fever and the formation of tumours and boils, and to the exan- 
thematous affections terminating in gangrene, sloughing of the 
the face, ulceration and discharge from the nose, &c« Sec. 



Dr. Eck on Glanders in the Human Subject. 93 

Finally, with respect to the treatment of glanders in the 
human subject, I must admit that, after a careful comparison 
of the results of all the cases which I have read, I have not been 
able to hit on any plan which T could pursue with any con- 
fidence in the management of future cases. It is undoubtedly 
of great importance, in the treatment of this as of other animal 
poisons, to endeavour by proper local treatment to fix and neu- 
tralize the poison before it gets into the system, and even when 
the commencing pains of the limbs, the incipient erysipelatous 
inflammation, the fever, &c. show that it has gone farther. 
Should this fail, and the disease become established, experience 
has shewn, that the assistance of art is at most extremely proble- 
matical ; and that the cures which have taken place after the 
internal and external exhibition of mercury, the employment of 
turpentine, evacuants of all kinds, whether emetic, purgative, or 
diaphoretic, the use of tonic and nervous medicines, bark with 
acids, chlorine, excision or cauterization of the boils and pus- 
tules, injection of kreosote into the nostrils, &c. were in all proba- 
bility the result of chance, or in other words, of the sudden and 
favourable exertion of the powers of nature, which, at other 
times, even under similar circumstances, does not manifest 
itself. Probably, in this matter also, the future brings us nearer 
to the goal. All we can do at present is to anticipate the evil, 
to attend carefully to all official medical reports bearing on the 
subject of glanders, and to remove as far as possible^ particu- 
larly from the minds of medical men, the opinion still too pre- 
valent, that this disease is not infectious, at least with respect to 
man. I trust the observations made in the foregoing communi- 
cation^ may elicit some further information. 



94 Dr. W. J. Geary's Report of 



Art. VIII. — Report of St. John^s Fever and Lock Mortals, 
Limeiick. By William J. Geary, M, D., Physician to Ihe 
City Infirmary, and Magdalen Asylum, and Assistant Doc- 
tor to the Hospitals. 

[Continued from Vol. XL p. 390.) 

From the many instances in which we have noted the pro- 
pagation of fever, either by direct contact with the sick, through 
the medium of wearing apparel, or from incautiously occupying 
apartments where persons had been recently ill of the disease ; 
we have been surprised how its contagious character could have 
been doubted, by those who had any fair opportunity of exa- 
mining the subject. It is true that the circumstances attending 
epidemic disease are so sufficient in explaining the appearance 
of fever, that a considerable amount of evidence becomes ne- 
cessary to assign its more general diffusion to contagion alone. 
One of the principal difficulties is to be found in the undefina- 
ble period, during which the disease remains latent, after the 
febrile poison has actually entered the system ; varying from a 
few days to as many weeks, a fact observable in variola and 
other eruptive effections, confessedly contagious. 

Like other narcotic poisons, that of fever seems to operate in 
proportion to its concentration ; where it is at the maximum of in- 
tensity, its effects on the cerebro spinal system are instantaneous, 
definite, and immediately manifested, while on the other hand, 
the amount being small, its effects are more gradually develop- 
ed, most probably through the agency of absorption. The in- 
teresting cases furnished by Dr. Marsh are referrible to the 
former class, and from what we have observed, tliose cases run 
the heaviest and quickest course, which are speedily developed 
after exposure to contagion. This may be explained by the 
great shock the system sustains, by the absolute intensity of the 
miasm^ by the pre-existence of the disposing cause in a high 
degree, or perhaps by all. For instance, during my attendance 



St. John's Fever and Lock Hospitals, Limerick. 95 

on die Dispensary in March^ 1827^ after walking a good deal 
during the day^ the weather being unusually warm, I visited 
a child, residing in a miserable, ill-ventilated cabin in Clare- 
street, who was represented to have been ill for several days 
before. The room in which she lay was very confined, and 
having no window, I had her brought to the door of the outer 
apartment, when she was found to be attacked with maculated 
typhus. 

Immediately after examining the case, I was senEed with 
nausea, vertigo, and a general chill. On returning home, I was 
unable to take any dinner, and on returning to my room from 
the table, I stated the circumstances, and my belief that I had 
canght fever. The disease set in that night, and so urgently 
did the acute symptoms supervene, that the head was leeched 
and blistered the next morning. The attack lasted for twenty- 
one days; and among other distressing symptoms svngulttts 
continued for seventy-two hours. 

It will be inferred, that my frequent intercourse with the 
sick, had established a predisposition so strong, that it only re- 
quired a small amount of exciting cause to produce the disease. 
Of thi» predisposition (if it existed) I had no appreciable know- 
ledge, as I never felt better than on going into the house. The 
illness appeared to me, then, to have proceeded from the state 
of concentration which the miasm had acquired, by the absence 
of cleanliness and ventilation. Other causes than the specific 
emanations from the bodies of the sick, are cpaable of produ- 
cing the disease, and with as rapid intensity. Among the most 
remarkable that came under our notice, were those arising from 
the continued operation of the effluvia of putrid animal matter : 
we have seen a very decisive instance of this kind, arising from 
the effluvia of a foul and ill-conditioned wound of the head, suc- 
ceeding an extensive fracture of the right parietal bone, with 
laceration of the dura mater. It occurred In 1S19, to my father, 
while attending an inquest on a young man, who died from the 
injury. H^Ing sat in the draft> he perceived the ** scent from 



96 Dr. W. J. Geary's Report of 

the wouncT* intolerably offensive^ and felt that he had then 
inhaled the poisonous dose. In the course of the day he be- 
came more sensible of his situation ; on the next evening he 
was obliged to yields and thenceforward continued in severe 
and dangerous fever for many days. A very singular case of 
fever occurred here, being the last year ; the exciting cause was 
the morbid impression of camphor on the olfactory nerves. 

Miss , a young and liealtby lady about^twenty years of age, 

walking by a chemist's shop in George Vstreet, was suddenly 
overpowered by the odour of camphor as she passed the door. 
She turned to her sister and exclaimed, ^' Oh, did you smell 
the camphor — I am sure to have a fever now !" her predictions 
were too truly verified ; she was attacked with the disease that 
night, and had a serious illness of several days' duration. This 
case is the more remarkable, as one of the lady's sisters had 
fever some years before, which was attributable to the ** smell 
of camphor !" 

We have endeavoured to trace the course of fever, through 
several members of families admitted into the hospital during 
the year. The inquiry furnishes 130 instances in which the 
disease was manifestly transmitted through members of dif- 
ferent families ; the total number of persons through whom 
the contagion was traced being 341, viz. 

8 members of a family admitted in 1 instance. 

do. in 2 

do. in 2 

dp. in 6 

do. in 9 

do. in 21 

do. in 89 

In each division the members of the family were admitted 
together or in close succession. Some had the disease from 
having come into close contact with the sick, others from sleep- 
ing in the bed covering in which they lay ; and again, more 
from inhabiting the rooms recently tenanted by the infected. 



7 


do. 


6 


do. 


5 


do. 


4 


do. 


3 


do. 


2 


do. 



Sl JohrCs Fever and Lock Hospitals, Limerick. 97 

We witnessed a well marked instance of the latter in the person 
of a Roman Catholic Clergyman who was seized with fever, 
on being translated to a parish, where the curate had but re- 
cently fallen a victim to the disease^ (1835.) He occupied the 
room where his predecessor expired, and though every pre- 
caution had been adapted to fumigate and disinfect the apart- 
ment, he was attacked with a lengthened and malignant illness. 
This zealous and estimable class of society, are constant victims 
to fever, which seems attributable to their close contact with 
the sick, as well as the length of time they are obliged to re- 
main in unwholesome and confined apartments; breathing a 
deleterious air, and exposed to the continued operation of con- 
tagion. This may be looked upon as the probable reason of 
the frequency of this disease among them ; even in cases where 
a constitutional predisposition can be hardly said to exist. In 
observing the transmission of fever, we have been often struck 
by the dissimilarity of supervening cases, with those from which 
they originated. Peculiarity of habit exercises at all times a 
well marked influence on the character of disease, and the 
modifications which are sometimes created do all but cloak 
the specific aflfection in obscurity. We have noted the first 
form of fever in a family as unequivocally typhoid, and though 
there could be no doubt, that other cases which appeared 
among them had their source in this case, they each assumed 
characters very opposite, the typhoid miasm not appearing 
to excite typhus ; and on the other hand, that form succeeding, 
where a different variety constituted the source. This is cer- 
tainly at variance with the strict identity which distinguishes 
the eruptive character of variola, rubeola, scarlatina, and other 
contagions diseases ; though we must admit, that there is oflen 
bat two much cause to regret the variability of the accompany- 
ing fever, when these affections prove epidemic. In a family 
consisting of seven, we have seen one aged seven years seized 
with typhus, and in a few days subsequent, four others taken 
ill. Of these one had scarlatina, two simple fever, and the 

VOL. XII. NO. 34. o 



98 Dr. Geary's Report of 

fourth aged fifty-six years> had fever with senile pneumonia : 
and again^ towards the close of 1828, measles having become 
epidemic in this city, we frequently noticed, in the months of 
November and December, several grown members of families 
attacked with fever, two or more days after the measles had 
appeared among the children. It is of consequence to state, 
that fever was less prevalent, during this and the two succeeding 
years, among us, thai\ at any period from 1 8 1 7 to the presen t. 

We abstain from extending this paper beyond its legitimate 
extent, by adding further instances of the transmission of fever 
from person to person. Sufficient, however, has been adduced 
to prove the fact, both by the immediately sensible impression 
which the introduction of miasm into the system has excited, on 
coming within the due limits of its ncilon, and the more gradttal 
(though not less satisfactorily traced) diffusion of the disease 
through different members of families admitted into the hospital. 
In treating this subject we should not forget, that the contagious 
property of fever, like that of hooping-cough, and scarlet-fever, 
is only known by its effects thus differing from small-pock, 
the plague, and other diseases which are communicable by 
direct inoculation. In fine, when we have carefully connected 
the circumstances of contact of the healthy with the sick in 
person, through the medium of wearing apparel, by the oc- 
cupation of apartments recently tenanted by the sick, we have 
accumulated the principal amount of evidence which such an 
inquiry admits of; and should an individual be seized with fever, 
after an exposure under these circumstances, we cannot tee any 
difficulty in assigning the attack to contagion. 

Children are much more liable to fever than is generally 
supposed, and to the little apprehensiveness of disease being 
transmitted by them, may be attributed the spread of disease 
through families in many instances. It will be seen under-* 
neath that nearly one-sixth of the admissions for 1836 were 
under ten years of age, a fact which bears out what we have 
stated, and is also a satisfactory proof of the increasing con* 



Sl John's Fever and Lock HoipUah, Limerick. 99 

fidence which public hospitals are acquiring from the coin<» 
munity. 

Table shewing the Number admitted at stated Ages of Jive Years ; 
their Relation and average Mortality per cent, from 6th Janu- 
ary ^ 1836, to 5th January, 1837, 



Ages, 


5 


10 

489 
13 

2J 


15 

762 
18 

21 


20 


25 


30 

304 
27 

81 


35 

100 
12 

12 


40 

203 
45 

22| 


45 

70 
13 

18i 


50 

82 
22 

27 


55 


60 


65 


70 

10 
5 

50 


s; 

o 


TotiO. 


Admitted, 


81 


701 362 

1 


23 


36 


2 
1 

50 


2 

1 

50 


3227 


Died, 


2 
2i 


37 


22 


5 


12 


235 


Average 
Mortality 
per cent 


5J 


6 


21J 


33| 


n 



By comparing the number of admissions and of deaths for 
successive terms of twenty years, it will be found, that the sus- 
ceptibility to fever diminishes, while the proportionate fatality 
augments with the increase of age ; viz. for the first term, in 
2033 admissions, the deaths were 3^ per cent., while for two 
succeeding periods of equal duration, the mortality reached 11 
and 25 per cent respectively, the admissions being 969 and 211. 
Of the entire treated for the year, full two-thirds were under 
twenty years of age ; and only one-third of the mortality 
occurred within that term. These deductions show satisfactorily 
the influence which age has, both on the extent and fatality of 
fever cases. We have already stated that fever maintains a 
steady augmentation amongst us. The annexed return shows to 
what extent ; and while we average this report, (July 29,) the 
numbers continue to pour into the hospitals to the same afflict- 
ing amount they did at this season last year. AH the exciting 
and predisposing causes are present in an unusual degree ; even 
constitutions the most habituated to its presence are obliged 
to yield ; and we regret we cannot indulge in any fair prospect 
of an improved condition of the poor, from which alone we 
might hope for a check to this scourge. Provisions now are 
scarce^ bad, and dear; ardent spirits abundant and cheap ; the 



100 



Dr. Geary's Report of 



weather variable and damp ; and there is a great want of em- 
ployment among the operatives and labourers. In a word, we 
have seldom known such absolute want and distress as is felt in 
Limerick at present. The parliamentary session has closed, and 
with it all the expectations of relief which its opening held forth. 
The discussions on the various measures of charitable relief sub- 
mitted to its consideration have proved angry and unsatisfactory ; 
and there appears but too much reason to apprehend a further 
delay to the final settlement of the Poor Law question ; a measure 
at once the most effective in checking the progress of contagious 
disease, and elevating the moral character of the lower orders. 

Quarterly Return, showing the Number admitted during each 
Season, from 6th January, 1836, to 5th January, 1837, the 
Mortality and general average percent. 





Admitted. 


Died. 


Average and 
General Mortality. 


Male. 


Female 


Total. 


Male. 


Female 


Total. 


spring, 
Summer, 
Autumn, 
Winter, 


259 
358 
375 
340 


315 
557 
610 
413 


574 
915 
985 
753 


18 
31 
25 
26 


24 
38 
37 
36 


42 
69 
62 
62 


n 
n 

64' 
8i 


Total, 


1332 


1895 


3227 100 


135 


235 


n 



The return does not include the number which remained in 
hospital at the close of 1835, nor the inmates of the establish- 
ment, many of whom were attacked with fever during the year. 
Mr. Swayne, the resident apothecary, and his wife, the house- 
keeper's daughter, the assistant register, and several of the 
nurses were ill, many of the latter more than once. The in- 
crease of disease was most observable during these periods, 
when the causes to which we have already alluded were most 
urgent The influence of sex appears in favour of the males, 
one-third less having been attacked than of the females. The 
greater delicacy of the latter, as well as the disproportionate 
amount of labour they undergo, slenderly clothed, and bare- 



St» JohrCs Fever and Lock Hospitals ^ Limerick, 101 

footed, seem to be the principal cause of their greater suscep^ 
tibility to fever. As regards the mortality, there does not ap- 
pear to be any remarkable difference, the proportion being 1 
in 13| of females, and 1 in 14 of males ; though that for six 
years, from 1814 to 1820, gave the proportion of females as 
22 to 15, a relative average, which commonly exists. The 
amount of deaths is much greater during the winter than any 
other season, which is owing to the complication of chest affec- 
tions among persons advanced in life, who are subject to the 
periodical aggravation of bronchial and pneumonic attacks at 
the time. Among the assignable causes of mortality, too much 
importance cannot be attached to the period of disease at which 
the sick are brought to hospital. It seems a well established 
point, that the chances of recovery are in the exact ratio of tlie 
period of illness at which the sick come under treatment. In 
this point of view, it is obvious that every thing is to be gained 
by the timely application of those remedies which are of known 
value in arresting or moderating symptoms,^where they are re- 
sorted to before the disease has obtained a fixed development ; 
we allude to emetics and purgatives princip^ly. The benefi- 
cial result of early treatment is clearly represented in the fol- 
lowing table, which shews the day of illness on which each case 
was admitted, number of cases, and deaths, with the ratio of 
mortality per cent, exclusive of forty-two Lock cases, fourteen 
infants sent out to nurse, and seven who died without being 
entered on the medical books, the latter being registered for 
coffins, and are here included in the mortality, from 6th Janu- 
ary, 1836, to 5th January, 1837. 



Dayof ill- 
nesswhea 
admitted. 


2 


3 


4 


m 

5 


6 


7 


8 
479 


9 


10 


11 


12 
41 


13 
16 
1 

64 


14 


Over 


TotaL 


NcKofCases'si |319 


484 


538 472'289 


170 


131 

1 


28 


67 
5 


88 
24 

27 1 


3206 


Deaths, 


8 


10 


22 


28 


33 


30 


36 


15 21 


2 


5 
12| 


235 


Mortality 
per cenL 


3| 


3J 


41 


54 


7 


10} 


n 


9 16 


7 


71 



102 Dr. Geary's Report of ' 

This gives the mortality of all admitted from the second to 
the fifth day, as ranging from 3^ to 5^ per cent, . while that 
from the sixth to the tehdi day, varies from 7 to 16 per cent ; 
this is an increase of great magnitude, and could the public be 
sufficiently impressed with the fact, it holds out the most con- 
vincing inducement for the early removal of the sick to hospital, 
a regulation, it should be remembered> not of advantage to the 
sick alone, but one of deep moment to the family, as such a 
course would be withdrawing the most apparent source of fever 
from amongst them. 

It is not necessary to remind those acquainted with extensive 
hospital practice, how the deaths are run up by circumstances 
entirely beyond the control of the physician, among these may 
be enumerated, the moribund state of many ; of this class we 
had seven, in such an extreme state of disease and exhaustion, 
that there was not actually time to have them transferred to 
the medical books before they expired ; and again of those ad- 
mitted in the last stage of disease and suSering , twelve died on 
the first, and eleven on the second day after they came in. 

Thus thirty should be deducted from the general mortality, 
which leaves a fair average of 1 in 15|. Further, the advanced 
age and feebleness of others; thus of fifty admissions aged 60 
years and upwards, nineteen died, being I in 3 ; and again, re- 
ferring to the influence of protracted removal to hospital, on 
recovery of 541 treated from the ninth day, upwards of seventy- 
three died, being 1 in 7, while of 2595 taken in from the se- 
cond to the eighth day of illness, 162 died, being only 1 in 23 
nearly. To these we may add the complications of fever with 
organic diseases, as phthisis, dysentary both acute and chronic, 
diarrhoea, &c. some of which remain latent till brought into ac- 
tion by the constitutional excitement there present. Among 
these, we have found chronic dysentery the most troublesome, 
arising from the use of unwholesome and innutritious food, and 
exposure to damp and cold. 

Dr. Mateer, in an interesting paper, to be found in the 



St. JohfCs Fever and Lock Hospitals, Limerick. 103 

Dublin Medical Journal for September^ 1836^ states, that he 
has not found the influence of trade or occupation, in the pro- 
duction of fever, so great in the manufacturing town of Belfast 
as may be supposed. Our own observations coincide with this 
view. We have a tabular view before us, which shews the 
number in families of each class of 2416 persons admitted 
from the city parishes, and the proportion they bear to each 
other ; though the exact relation to the general population can- 
not be determined, as there is considerable difficulty in as- 
certaining the amount of each trade. However, as may be ex- 
pected, the labouring class being the most numerous, constitute 
the largest number, averaging one-half of the entire ; and in- 
cluding all we find that more than one-half of those treated for 
the year cannot be said to be of any trade, viz., females and 
children. We have elsewhere stated that the patients re- 
ceived from the county constituted one-sixth of the whole. 
The exact number is 567. They principally came from damp, 
boggy districts, and their abodes were distant from Limerick 
from five to sixteen miles. 

To the interposing protection of the Fever Hospital in this 
city, we essentially attribute the escape of the humbler classes 
from the spread of pestilence and death ; and to it there can 
be as little doubt, the wealthier part of the community owe 
their immunity from contagious fever. Dr. Currie supposes 
** every single removal into the house of recovery probably 
prevents, on an average, two or three cases of the disease," and 
Dr. Haygartt is of opinion, ^^ that of twenty-three persons ex- 
posed to contagion, only one escapes.'' 

We have now brought the statistical arrangement of the 
yearns occurrences to a close, and though it proved a term of 
anxious exertion, we have the gratifying conviction that the 
united and zealous attention of all the individuals connected 
with the institution, have insured in a remarkable degree the 
success which attended the labours of the medical officers. 



104 Dr. GevLty^a Report, SfC. 

Number of patients admitted, 3,269 

Aggregate number of days in hospital, . . • 60,613 
Average number of days of each patient, . . . 1 5| 

Total expenditure for the year, £1668 6 10 
Average expense of each patient, 10 2| 



BIBLIOGRAPHIC NOTICES. 



A Treatise on the Malformation^ Injuries y and Diseases of the 
Rectum and Anus. (Illustratea with Plates.) By George 
BusHE, M.D., formerly Professor of Anatomy and Physi- 
ology, &e. New York. 8vo. pp. 299. 

Dr. Bushe, once doubtless personally well known to many of 
our readers, received his medical education in this city, and in 
consequence of his distinguished abilities, having received a so- 
licitation to accept the chair of anatomy in New York, left this 
country some years ago for that purpose. Hq finally settled 
as a practitioner in New York, and had just risen to the first 
practice, when, after long suSerine, he sank a victim to con- 
sumption. For many years the diseases of the rectum had 
engaged his attention ; and as he informs us— 

" My opportunities for inveBtig^ting them have been ample, and 
I may safely say, that I spared neither time, trouble, nor expense in 
endeavooriog to arrive at just conclusions." 

The result is the work before us, to which he had just time to 
put the finishing hand when he expired. After a careful 
perusal, we cannot but regard it as a very valuable addition to 
the works dready published on the subject. The style is con- 
cise, clear, and highly descriptive ; and there is not an opinion 
of any importance but is supported by the author's actual obser- 
vation and experience. As there is but one copy of the work 
(as far as we know^ in Dublin, and as we are anxious to put our 
readers in possession of as much of the valuable matter con- 
tained in it as possible, we shall not take up more space in 
Seneral remarks, but proceed to consider the subject more in 
etail ; and by the copiousness of the extracts, it is our inten- 
tion to render each person able to form his own opinion of the 
book. It begins with the anatomy of the rectum and anus, 
which oflTers nothing worthy of note, except that our author 
denies the existence of valves in the rectum ; what have been 
usually described as such, he looks upon as merely mucous folds, 
which disappear on the distention of the intestine. To Dr. 
Houston he objects, that — 

VOL. XII. NO. 34. p 



106 ' Bibliographic Notices. 

'' His method of investigation gave rise to his misapprehension of 
this piece of anatomy : one hj filling the intestine with alcohol, and 
then opening it ; the other, by inflation and drying. In the first, the 
accidental folds are rendered permanent by the induration resulting 
from the action of the alcohol ; while in the second, the projections 
resembling valves are produced by the angles formed by the settling 
of the intestine during the process of desiccation." 

We confess we do not see the force of these objections, espe- 
cially the last ; and according to his own shewing, (in a long 
note,) he has against him the respectable authority of Morgagniy 
Portal, Boyer, Glisson, and H. Cloquet. After all, how strange 
it appears, that a matter apparently so easy to demonstrate, 
should have given rise to such difference of opinion ; we cannot 
help thinking that it is a quibble about words, and that the 
mucous folds, which all allow to exist, do in realiW act as valves 
in the moderately distended state of the rectum, but gradually 
disappear in proportion to the gradual distention of tlfe gut, 
and finally become obliterated, and cease to act, when their 
further action would not only be useless, but serve to keep up 
an injurious retention of the faeces. 

The treatment recommended for one form of malformation 
of the rectum and anus calls for some remark : — 

*' Where the rectum is partially absent, an anus ought to be 
made if possible in the natural situation." 

To accomplish this. Dr. Bushe recommends, after dissecting to 
about the depth of two inches, or at most two inches and a 
half,— 

"If the bowel is discovered by its blackness and flnctoalion, 
either a trochar, or what is better, a bistoury, should be forced into 
it, and the meconium evacuated. The opening thus formed should be 
maintained by tents of prepared sponge, &c.*' 

But he allows that most surgeons who have performed such 
operations have been unsuccessful. In short, so ratal is this ope- 
ration, that we do not think Dr. Bushe would have recom- 
mended it, had he been aware of the admirable one proposed 
by Amussat. A translation of Amussat's paper is given in this 
Journal,* by the perusal of which such of our readers as are not 
acquainted with it would be well repaid. We may briefly state 
that Amussat was led to believe, from several fatal cases he had 
witnessed, and from experiments on animals, that death was to 



* Dablin Joarnal, vol. iz. p. 338. 



Dr. Bushe on Malformation, Sfc, of the Rectum and Anus. 107 

be attributed to the absorption of some parts of the fecal matter 
by the sides of the incision. He therefore obviated this bj ope- 
rating in the following way : having cut down to the bowel^ he 
freed its connexion with the neighbouring parts in a great 
measure with his finger, he then drew the end of the bowel 
down with a hook beyond the lips of the wound, to the sides of 
which he fastened it with many points of suture. It was then 
opened, and the meconium let out; the artificial anus thus pro* 
duced, kept open by spout tent, conical wax bougies, &c. The 
writer of this review can state, that a child thus operated on 
about a year ago is well and thriving, and the anus a remarkably 
efficient one. 

The description of fissure of the anus is so very good, and 
the treatment of this distressing complaint, although offering 
little novelty, so very judicious, that we shall quote largely. 

^' The disease so named is an ulcer, about the eighth of an inch 
in breadth, and from a quarter to an inch in length, situated imme- 
diately within the anus, generally on one or both sides, occasionally 
on the posterior, and stiU less frequently on the anterior part of the 
aperture. In the majority of cases it is con6ned to the mucous mem<r 
brane, though occasionally it extends to the muscular tissue. Its in- 
ferior extremity generally corresponds to the edge of the external 
sphincter, though sometimes it is placed a little higher up or lower 
down. The base of this oblong ulcer is generally red, but sometimes 
grey, in consequence of the deposition of lymph. When recent, its 
edges are soft, pliant, and but little elevated; in proportion, however, 
as it becomes chronic, so are they more hard and prominent; 
changes which depend upon the interstitial deposition of adventitious 
matter from the irritated capillaries. 

*' The surrounding mucous membrane is in its natural state in 
some cases, particularly when recent, but not un frequently it wears 
an erysipelatous hue, and again assumes a livid aspect, and becomes 
soft. Women are more subject to this affection than men, which 
arises from their leading more sedentary lives, and consequently being 
more subject to constipation of the bowels. It generally occurs in the 
meridian of life; nevertheless I have treated a case in a girl of 18, 
and another in a woman 69 years of age. 

*' In the majority of cases it is preceded by vascular tumours of 
the rectum, then it is situated between two of them, and is produced 
by the forcible passage of indurated faeces. In this act the vascular 
tumours are first prolapsed, and then separated, during which process 
the mucous membrane, rendered friable by inflammation, is ruptured. 
The contraction resulting from operations performed in this region, 
and the spasm of the sphincter, by opposing the free egress of the 
fseces, become a frequent source of fissure in the former, by disposing 
to rapture, and in the latter, by contusion and abrasion of the mucous 
membrane. 



108 ' Bibliographic Notices^ 

^' In three different instances I have mentioned, thia laceration of 
the mucous membrane does not heal, because the primary affection 
still continues ; and even in some instances, as heretofore explained, 
the rupture is converted into an ulcer, though no primary affection 
existed. 

** Besides the causes now specified, inflammation, and consequent 
abrasion, may, from the columnar arrangement of the mucous mem- 
brane of the lower extremity of the bowel, give rise to one or more 
fissures. 

" In the commencement of this disease, the symptoms are not 
severe, being merely at one time a pricking or stinging sensation, at 
another, a slight smarting in a certain point of the anus, which, un- 
der the use of lavements, and low diet, subsides either altogether, or, 
after a few days, returns with some severity. The pain gradually 
increasing, becomes burning, sometimes lancinating, and when se- 
vere, throbbing. It is increased by forced expirations, as coughing, 
sneezing, and urinating. Every effort to discharge gas and faeces is 
attended with excruciating torment, which continues for one or more 
hours, attended with violent spasmodic action of the sphincter ani. 
So violent is the agony, that most persons thus afflicted put off the 
calls of nature, maintain the recumbent posilion, and some even avoid 
taking a proper quantity of nourishment, for fear of increasing the 
fecal mass. The pain is always increased by stimulating food ; and 
in females, during menstruation. Occasionally I have seen it assume 
a periodical character, which depended upon some peculiar state of 
the constitution. When the feeces are solid, they are slightly 
streaked with blood and matter ; and when more soft, are figured, and 
of small size. To examine the fissure, the buttocks should be forcibly 
divaricated, when its inferior extremity will be brought into view ; 
but in some rare instances we cannot accomplish this object, in conse- 
quence of its elevated site, and we are compelled to trust either to 
the introduction of the finger, or to the dilatation of the anus with the 
speculum for its detection. In a few cases, though it is immediately 
discovered upon separating the buttocks, we can only ascertain it by 
the means just mentioned. 

'' The introduction of the finger is attended with g^eat difficulty 
and torture, particularly when pressure is made on the fissure, which 
seems, in some instances, to be a mere depression, in others, to be 
surmounted by pretty high edges, while in a few rare instances, we 
only become cognizant of its situation by the increase of sufferuig in 
a certain point, under the same amount of pressure. When the pain 
is violent during and after stool, it is accompanied by fever ; and 
when it continues for any length of time, emaciations, hypochondria- 
cis, and an irritable state, with a severe trace of nervous symptoms, 
ensue. 

*' During the treatment of this disease, the patient should be 
kept on a low diet, and confined to the recumbent position. The 
common practice of administering cathartics, so as to produce fluid 
evacuations, cannot be too highly censured ; for such discharges sti- 



Dr. Bushe (mMalformatioihSfc. of the Rectum and Anus. 109 

mnlate the ulcerated surface, and thus induce dreadful irritation and 
spasmodic contraction of the sphincter ani ; therefore, the better 
jAan is to administer daily an enema of flaxseed tea, and after its 
operation to cleanse the parts well. If the disease be mild, the ap- 
plication of the unguentum acetatis plumbi will be sufficient for its 
healing, and if there be much spasm of the sphincter, the extract of 
belladonna will prove a powerful auxiliary. Dupuytren recommended 
an ointment of this kind, the proportions being a drachm of the lead, 
and the same quantity of the belladonna, to six drachms of lard. Be- 
fore I became acquainted with this practice, I was in the habit of ap« 
plying the nitrate of silver to superficial fissures attended with spasm, 
and then introducing washes of lint, besmeared with a mass consisting 
of one part of the extract of belladonna, and seven of spermaceti 
ointment, a course of practice which has succeeded when Dupuytren's 
ointment has failed." 

We may observe, that besides his own and Dupuytren's 
method of applying the belladonna and acetate of lead, we have 
seen another used by the Surgeon General with i^reat benefit, 
namely, the continued application of a pledget of lint, wet with 
the following lotion : Liquor Acet. Plumbi, ^vi. Ext. Bella- 
donnae 311. 

<* When a fissure will not heal under this treatment, and the 
patient continues to suffer, we should no longer delay the division of 
the sphincter, which never fails to give immediate relief, and to efifect 
a rapid cure. 

If the fissure is situated on the anterior or posterior part of 
the intestine, as the division of the sphincter and not the fissure 
is the desirable object, he prefers the incision to be made at 
either side ; and thus — 

'' The inconvenience arising from the shortness of the space be- 
tween the coccyx and verg^ of the anus, the proximity of the bulb 
of the urethra in the male, and the shortness of the perineum in the 
female, is avoided, as well as the difficulty of healing wounds made 
in the median line in this situation, in consequence of the friction 
created by the motion of the inferior extremities." 

A dose of morphine immediately after the operation, low diet, 
and an emollient lavement should be exhibibited daily, till the 
woand heals, which is in about three weeks. Both the chapters 
on neuralgia of the rectum, and spasmodic contraction of the 
sphincter ani, convey clear descriptions of these affections, and 
many original cases of much interest are given in support of his 
particular views. He oflfers no opinion as to the primary cause 
of the neuralgia, but regards it as of the same nature as nervous 
pains elsewhere. In two of his cases there was also tic 



1 10 Bibliographic Notices. 

douloureux; in the last, that of a delicate voung lady* tic 
douloureux of the face, of a most aggravated character^ im- 
mediately followed the cessation of the pain of the rectum. In 
another case, after antispasmodics, suppositories, enemata, the 
local application of extract of belladonna had failed, division 
of the sphincter completely succeeded. 

Spasm of the sphincter he often found connected with ir- 
ritation of the genito-urinary organs, irritable bladder for in- 
stance, with mucous deposit, and excess of lithic acid in the 
urine, and succeeded in removing it by the administration of 
soda, injection of the bladder, with solution of gum-arabic, hip- 
bath, inild laxatives, &c. The great omission here is the 
absence of any allusion (except in a solitary instance) to the use 
of the bougie. Now any one who has read Mr. Copland's 
excellent observations on painful spasmodic contraction of the 
anus, and his strong advocacy of the bougie for its removal 
must feel surprised at our author's silence on this head, as well 
as his not even mentioning Mr. Copland's name while treating 
of the subject, although other parts of the work shew him to 
have been quite familiar with that experienced surgeon's book. 
With Montagu our author regards the rectum to be frequently 
the seat of determination of blood, giving rise to discharges of 
blood of variable quantity and frequency, the formation of 
haemorrhoidal tumours, inflammation, and mucous discharge. 
We shall confine our attention to '' hemorrhoidal tumours," or 
piles, because the chapter on them is not only the most valuable 
of the whole work, but that we really think it conveys to our 
mind a finer description of the disease than we have met with 
in any of the many books we have read on the subject; from 
the frequency of toe aflTection, too, it possesses unusual interest 

** Tumour$, — Generally after the blood has accomolated im- 
moderately in the rectum several times, but occasionally as the 
result of the first congestion especially, when there has been no 
hsBmorrhage, tumours form, in consequence of the opposition ofiered 
by the structure of the rectum to the escape of the blood. These 
tumours may be divided into two classes, the first is situated within, 
and the second immediately without the anus. 

** Those situated immediately within the anus, vary in number, 
in many instances being so numerous, as to prevent the free dis- 
charge of fsdces, while (in other cases they are few, even solitary. 
Their sise b as variable as their number, difiering from that of a 
small pea to a pullet's egg. They are generally globular, and in 
many instances pedunculated, particularly when large, and subject to 
prolapse during defecation ; for under such circumstances they swell 
and suffer a constriction at their bases, from the contraction of the 
sphincter. Generallj, they are of a dark red colour, and when pro- 



Dr. Bushe on MiU/ormationf 8fC., of the Rectum and Anus. Ill 

I^Md, they beoono perfectly liTid, ia conBeqoence of the obetniction 
created to the return of the venous blood ; firstly, by the forced ex- 
pinitioDs necessary for the act of defecation ; and secondly, by the 
constriction of the sphincter. 

<< I hare repeatedly injected these tmnours with coloured water, 
both from the arteries and veins, and when cut into while the fluid 
was projected, small jets were observed to issue from many points* 
I have frequently dissected them with the greatest care, and found 
that they were spongy, reddish, and contained both arteries and veins, 
the latter being most capacious, but always perfectly healthy. Their 
surface is villous, and generally bleeds when touched roughly, or 
scratched with the nail, the blood which issues being of a florid red 
colour. In many instances, I have been able to rub off exceedingly 
vascular and fragile adventitious membranes from their surface. 
Thus it would seem, that they may acquire an increase of magni- 
tude in this way." 

Dr. Bushe has here given his opinion, thathaemorrhoidal tu- 
■loiirs are made up df a sort of erectile tissue composed of arteries 
and veins, and in a long note he denies that a varicose state of 
the veins ever forms them. In this note he gives a list of the 
most eminent men who have written on the subject, from which 
it appears that the two latest, if not the best writers, Jobert and 
Dupuytren, consider them to be varices, while a whole host of 
<yther8, among whom are Abeniethy, Cruveilhier, and Cham- 
pier, are of tte opposite opinion, and agree with our author. 
But a later writer than any of these, and one whose opinion on 
any subject relating to pathology is entitled to the utmost con- 
siaeration, but of whose woiIl Dr. Bushe appears not to be 
aware. Dr. Carswell, considers tliat hsemorrhoidal tumours 
nmy be formed by either of these structures. From the view 
of an admirable {date of a rectum the seat of these tumours, 
the truth of the following opinion is manifest ''There are 
two forms of this disease, the more common of which depends 
on dilatation of the veins of the rectum ; the other on a trans- 
formation of the dense cellular tissue of the margin of the anus 
into erectile tissue." — Fasciculus VL 

** When these tumours are small, they are generally attended 
with slight heat and itching, but as they enlarge, they produce a dis- 
agreeable sense of fulness in the lower extremity of the rectum, and 
are prolapsed during defecation, after which they gradually shrink up, 
and by the action of the musctdar apparatus of the anus, are returned 
to their original situation. In some cases, however, the sphincter 
becomes more or less relaxed, and these tumours, in descending, drag 
aloog with them a portion of the adjacent mucous membrane. In- 
deed so large is the protrusion, that persons thus afflicted are com- 
pelled to return it with their fingers ; and many of them postpone the 



112 Bibliographic Notices. 

calls of nature, until they are about to retire for the night, in conse- 
quence of the difficulty they experience, and the time they require to 
reduce it ; and above all, as they can only e£fect this in the horizon- 
tal position. In many cases the protrusion occurs when the patient 
walks, or even attempts to ride in a carriage, and thus gives rise to 
great uneasiness and mucous discharge. Besides the protrusion of the 
mucous membrane now described, that of the pouch frequently takes 
place from the constant nisus these tumours are apt to create. 

" In a few cases, when there is but one tumour, it is situated low 
down, and though not large, partially projects through the sphincter, 
and gives rise to very great annoyance. In a case of this kind, on 
which I operated a few days since, the mucous discharge was very 
considerable, the surrounding parts were much engaged, and the 
patient not only su£fered from the friction which his clothes exercised 
on the tumour, but also from a constant teasing nisus, with occa- 
sionally irregular and painful contraction of the sphincter. However, 
the relief which he obtained from the removal of the tumour was 
immediate and permanent. 

'' In consequence of the irritation and pressure of the feculent 
matter, as well as the effort necessary to dislodge it, blood accumu- 
lates in the rectum during defecation, so that though there has been 
no previous haemorrhage, these tumours may exhale blood ; and in 
such cases it very often happens that it is squirted out from one or 
more dilated pores. Sometimes, though rarely, these tumours do not 
bleed for weeks or months ; but I never yet have seen a case in 
which they did not bleed at some time. Generally, indeed, when 
they exist, they are the source of the sanguineous discharge which 
occurs, though previous to their appearance, the mucous membrane, 
as before pointed out, gave rise to it ; and a most extraordinary fac^ 
which I have verified repeatedly, is, that when they have been 
removed, the mucous membrane has again become the organ for 
throwing off the superabundant blood. 

** When we consider the structure and situation of these tumours, 
we ought not to be surprized that they very often become inflamed, 
increase much in size, are attended with great pain, muco-purolenr 
discharge, and disorder of the urinary organs. In this state, pro- 
vided the tumefaction be great, the patient feels as if there were 
foreign matter in the rectum, straining ensues, and they are prolapsed ; 
now the sphincter becomes affected spasmodically, and presses on 
their radices, giving rise to great suffering. The inflammation may 
subside in one, two, or three days, and then these tumours will either 
recede of themselves, or the patient be enabled to return them in the 
usual manner; but it sometimes happens, that the sphincter con- 
tracts with so much force as to strangulate them, and cause mortifica- 
Uon; an event which generally effects a radical cure, though a few 
cases are recorded in which the issue therefrom was mortal. Of 
four cases of this kind which I have seen, three terminated favourably, 
one fatally. 

** It not unfrequently happens, that in consequence of inflamma- 



Dr. Bushe on Malformation, 8fc. of the Rectum and Anus. I (3 

lion, in these tumours, small abscesses form in them, attended with a 
discharge of purulent matter from the anus, and more pain and irrita- 
tion of this part than usual. Such cases are far from being uncom- 
mon, and are too often overlooked. To detect these small fistul?e, 
the finger ought to be cautiously introduced, and after a little explo- 
ration, a small depression, marking the fistulous orifice, may be dis- 
covered on each tumour thus affected. But should this attempt fail, 
the buttocks ought to be forcibly separated by an assistant, while the 
patient bears down ; then with a strong light, and a probe of small 
size the sinus will be easily found. In the majority of cases but one 
tumour is fistulous, though I have occasionally seen two or more so. 

" Occasionally these tumours are attacked with ulceration, and in 
such cases it generally seizes on many points at the same time, but 
seldom advances to any great extent. I have, however, seen a case in 
which three very large hsemorrhoidal tumours were one- half consumed. 
And in the twelfth chapter, p. 1 38, f have related another, which iS in- 
terestingon account of the phagedenic character of the disease. Haemor- 
rhage is sometimes the result of the ulcerative process, as I had an op- 
portunity of observing in the two following cases : — Mr. C, a gpentle- 
man advancing in life, of full habit, and subject to haemorrhoids for 
many years, during a salivation which resulted from the mercurial treat* 
meat of a severe fever in the West, was attacked with more than usual 
uneasiness, and purulent discharge from the rectum while at stool. Id 
a few days he began to bleed; and so much did this increase, that he 
repaired to New York, and became my patient. He was very low 
from loss of blood, and distressed in mind. I made a careful exami- 
nation, and found four hfemorrhoidal tumours, one of which was as 
large as a peach stone, and ulcerated deeply. When he strained, all 
the humours were prolapsed, and florid blood issued freely from 
the ulcerated surface. I removed the tumours, and he soon regained 
his health. The other was that of a planter from Louisiana, who ar- 
rived here this summer, on his way to Paris to be operated on ; but so 
low was he when he reached this city, that he felt unable to proceed, 
and, therefore, sent for me, and had the operation performed. In this 
case there were several ulcerated points on each tumour ; and though 
they were superficial, the haemorrhage from them was very brisk; 
Notwithstanding I have seen several cases of ulcerated haemorrhoidal 
tumoars, those are the onl^ ones that were haemoirhagic, and this I 
am inclined to attribute to the condensation which they generally un- 
dergo from repeated attacks of inflammation, previous to the com- 
mencement of the ulcerative process. 

" Though these tumours maintain their spongy structure for 
years, yet it occasionally happens that, from constant irritation, they 
become transformed into a semi-cartilaginous mass, being firm, 
yellow, and nearly bloodless ; I saw a case some weeks ago in a lady, 
who visited New York for the purpose of having them removed. I 
performed the operation, and two of the tumours are represented in 
plate, &o. 

" In some cases, when we cannot detect any other lesion, and 

VOL. xu. NO. 34. Q 



1 14 JBibliographic Notices. 

these tninotir9 appear perfectly free from engorgemeuti tbe patient 
who is geoerally of a nervous constitution, is affected with contrac- 
tion of the sphincter ani, and exquisite pain, which, when violent, ex- 
tends to the uterus, vagina, and external organs of generation in the 
female, to the perineum and testicles in the male, and to the bladder 
and urethra in both sexes. The constant tenesmus, stranguary, and 
dysury which it produces, wears the patient down, giving rise to 
sleeplessness, anxiety, and fever, and in some rare cases, so excruciat- 
ing is the pain, that the patient must remain perfectly tranquil, as the 
least motion exasperates his sufferings to an intolerable degree. As 
these cases are not of common occurrence, the three following may 
prove interesthig." 

In three cases our author removed the tumours with com* 
plete success. 

'* The second class of tumours are those situated on the verge of 
the anus, though I have seen a few cases in which they extended a 
short way within this orifice, being in part covered with the mucooa 
membrane. They are more or less livid, generally elastic, have an 
extensive base, and are formed of extravasated blood, which is en- 
cysted by condensed cellular tissue, and covered by a few fibres of 
the sphincter and fine skin of the verge of the anns. I have satisfied 
myself of these facts, by cutting off the prominent portion of the tu- 
mour, and then burning out the extravasated blood in the living 
body, and by cautious dissection in the dead. Sometimes the blood 
is absorbed, leaving no trace behind ; occasionally, however, in conse- 
quence of Uie first, bat more especially of repeated attacks, the su- 
ptrincumbent integuments and surrounding cellular tissue, become 
hypertrophied, and pendulous flaps or tumours, which in some in- 
stances, from tbe friction they are exposed to, obtain a rough or 
warty aspect, and become a source of great irritation. It not unfre- 
quently happens, that when there b but one large tumour, it suppu- 
rates, and then gradually shrinks up. When small, these tumours 
are attended with itching, and sense of fuhiess and pain on prea- 
sure ; but when large, the pain is constant, and is accompanied with 
more or less throbbing, and sometimes contraction of tbe sphincter. 
Indeed so severe is the anguish, that tbe patient is feverish and un- 
able to walk, or take any other species of exercise, especially if sup- 
puration be about to occur. 

'* These tumours, when recent, are apt to be confounded with in* 
ternal tumours, and partial prolapsus of the rectum. They may be 
distinguished from the internal tumours by being covered principally 
by the /skin ; by smoothness of surface ; by our ability to glide the 
superincumbent parts over them; by their greater lividity; and 
finally, by their excessive hardness and freedom from hemorrhage. 
They differ from partial prolapsus of the rectum, not only by their 
density and lividity, but, by their greni tenderness and tubercular 
foi m. However there is occasionally but one tumour, which is very 



Dr. Boshe on Mal/drmatian, S^c. of the Rectum and Anus, lid 

farge and flat, with the mucous memhrane stretched over its internal 
and inferior aspect, so as to simulate very much a descent of a por- 
tion of the mucous membrane. The diagnosis, however, is by no 
means so difBcult, for, independent of its deeper colour, firmer con- 
s'istence, partial cutaneous covering, and limited extent, if the finger 
be introduced, the tumour will be found to extend a considerable 
way within the sphincter. 

'* When these tumours undergo the changes I have before men- 
tioned, they are liable to be confounded with excrescences which form 
about the anus, and are sometimes of a venereal character. They 
may, however, be easily distinguished from them by the history of 
the case, by the absence of other venereal symptoms, by the pliability 
of the skin ; by the healthy condition of the surrounding parts ; by the 
absence of a purulent secretion ; by their lighter colour ; generally, by 
their greater density and roughness ; and finally, by being confined to 
the verge of the anus.'' 

The length of these extracts has somewhat exceeded our 
Kmits^ but Dr. Busbe's delineation of the disease is so just and 
accurate^ that we did not wish to spoil it by curtailment. Tn 
this acconnt however^ otherwise so perfect^ we cannot bat re- 
^t his total silence about a most important train of symptoms 
incident to long continued bleedins from piles, we mean those 
derangements in the circulation which proceed from reaction. 
Pain, dizziness, and lightness of the head, with noise in the 
ears, simulating the symptoms from a totally different cause, 
plethora, sometimes arise. Violent and constant palpitation of 
the heart with anasarca is another form. We remember to have 
beard the Surgeon General in his lectures relate a case of this 
description, where the original affection was entirely overlooked, 
and the treatment directed to the relief of the supposed disease 
of the heart, for a long time injuriously, but which was finally 
quite cured by the appication of a ligature to the piles. Nine 
years after this operation we assisted in a similar one on the 
same gentleman for a return of the piles, he having enjoyed ex- 
cellent health in the mean time. Two other cases have lately 
come under our observation, where the symptoms of the heart 
completely masked the primary disease. It would be a waste 
of words to insist on the importance of a right understanding 
on this head. 

After discussing the treatment of congestion and hsemor- 
rliage, depending on flux to the rectum, he proceeds to describe 
ibat of haemorrhoidal tumours. 

''When the tumours are exceedingly painful they should be 
anointed with the following salve, three or four times a day. 

9> ^t. Opii grana duodecim, 
Ung. Cetacei unciam, M. 



116 . . Bibliographic Notices* 

Sometimes the patient derives great relief from the. applicatlen of 
cold water in a continued stream. Thus in England many of those 
afflicted with haemorrhoids are in the habit of allowing the stream 
which issues from the water-closet, to strike against the part pro- 
lapsed, while defecating. When the sphincter ani is affected spas- 
modically, I have found the following ointment very useful : 

]^ Ext. Belladonna drachmam, 
Ung. Cetacei unciam. M. 
Should the tumours be inflamed, leeches ought to be applied to the 
surrounding parts, and followed by tepid cataplasms. Some authors 
have recommended scarifications, but, 1 cannot approve of this 
practice ; firstly, because I have seen much annoyance, and never 
any good arise from them ; and secondly, because the principle upon 
which they have been recommended is erroneous, viz : that as piles 
are dilated reins, their puncture ought to afford much blood, and 
thus disgorge the vessels of the rectum. When they descend, and 
the surrounding parts are relaxed, we may advantageouly use 
ihe ointment of galls. In consequence of pain it may be advisable to 
add opium, or of spasm of the sphincter, belladonna to this ointment; 
and should there fa« ulceration, and fungous asperities on their surface, 
the super- acetate of lead will prove a useful addition, in the pro- 
portion of half a drachm, or even a drachm, to an ounce. 

" Where the spasm and pain did not forbid it, I have ordered 
half a drachm of the sulphate of zinc, in half a pint of water, to be 
injected every morning after defecation, and in the evening a steel 
bougie to be passed a few inches into the bowels, and kept so for half 
an hour. This plan has in some instances answered very well, and 
on the whole, appears to me much more useful than it was esteemed 
by those who first tried it. 

'* The means now stated are sufficient, in the majority of cases, 
to enable the individual to pass his life comfortably ; but when, in 
spite of their judicious employment, the tumours continue to be 
neuralgic, attended with spasm of the sphincter, subject to protrusion, 
or bleed profusely, they ought to be removed. 1 must here, however, 
caution the inexperienced against precipitate determination, and this 
1 cannot more effectually do, than by repeating, that hemorrhoidal 
affections are generally constitutional, and serve to ward off fatal 
disease of other organs, therefore, it is absolutely necessary to in-* 
terrogate the patient as to his hereditary predisposition to other 
disease, to the present state of the organs most essential to life, to 
his health previous to the formation of these tumours, and the in- 
fluence they have exerted on it. Having, after a mature considera- 
tion of his case, determined upon the propriety of removing them, 
the patient ought to be informed of the course of treatment, which 
we shall specify in another place, as necessary after the operation, 
and without he consents to pursue it, the surgeon ought not to pro- 
ceed to operation. Indeed, when we meet with a rational patient, we 
ought to explain to him all the circumstances relative to his case, or, 
if he be not a sound thinking person, it will be prudent to confer 



Dr. Bushe on Malformation^ Sfc. of t/te Rectvm and Anus. 117 

with some of bit' friends ; a course not only proper in this, but in all 
ocber cases wbicb may present tbemselves for operation." 

Veiy judiciously, we think, he is a decided opponent to ex- 
cision. In applying the ligature on piles, he recommends tlie use 
of several instruments of his own invention, but for which, as the 
description without the plates would convey but a confused idea, 
we must refer our readers to the work itself. There is one point 
in his directions for this operation, against which we must enter 
a decided protest ; after a needle, armed with a double three 
silk ligature, has been passed through the tumour, and the 
needle removed, he says — 

" Each half of the tumour being tied as firmly as possible, all of 
it, save a small portion in front of the ligature, ought to be cut off 
with a curved scissors." 

Often as we have seen this operation performed, we never saw 
any inconvenience from leaving the tumour after the application 
of the ligatures ; but it is not a week since we saw a ligature, 
although applied very tightly, slip off. Nothing worse than the 
repetition of the operation was the consequence ; but had the 
direction of our author been followed, and the tumour cut off 
beyond the ligature, heemorrhage, the objection to excision^ 
would probably have caused mucn trouble and danger. 

There are other subjects of much interest, and equally well 
treated, which we should have wished to have considered, par* 
ticularly abscess near the anus, fistula, and stricture of the rec- 
tum ; but this our want of space forbids. In reviewing the work 
we have not hesitated to say where we differed from the author, 
or to point out where we thought him wron^ ; this, we are 
happy to sav, has not been often necessary ; mdeed, from the 
general excellence of this treatise, we cannot doubt but that it 
must rank high as an authority on this class of diseases. With 
respect to the mechanical part of the work, if we are to regard 
it as a specimen of American typography, our Transatlantic bre- 
thren are sadly behind us in this respect ; even at the beginning 
the printer has printed his own name so badly, that with much 
difficulty we discovered it to be James Van Norden. Dr. 
Bushe, in the preface, claims, very fairly, the reader's indul- 
gence for there being many mistakes, which from his ill health 
he was unable to correct ; but there are printer^s mistakes in 
almost every poge^ such as larceration, gra^, di/estion, conges- 
tion, dilated sulphuric acid, &c. not to mention parts of French 
quotations perfectly unintelligible, on which we are not inclined 
to bestow the least indulgence, as such slovenly printing would 
be disgraceful to any press. Although so short a time in Ame- 



118 Bibliographic Notices. 

rica, the anthor too occftsionally fells into Amerieanisms : — *^ A 
gentleman came to me last /a// /" " I touched the surface with 
a swab soaked in nitric acid ;** " a cane of the nitrate of silver;" 
&c.; but these are perhaps trifles scarce worth noticing. ^ 

We cannot bring these observations to a close, without a 
melancholy feeling of regret, that death should have so soon 
arrested the workings of a mind from which such benefits to 
science might have been anticipated. 



J%e Philosophy qf-Human Nature in its Physical, ItUellec- 
tualy and Moral Rekuions. By Henry M'Cormac, M« IX 
London, 1837. — Longman. 

We regret that the subject matter of Doctor M^Conmu^s book 
16 of a nature which does not permit us (consistefiitly with the 
plan laid down for the conduct of this Journal) to lay before 
our readers a sketch of its contents, or indulge ourselves in 
making extracts from tlie work itself. Doctor M^Cormac is 
already very favourably known to the profession by his Essay on 
F^ver, and we have no doubt that his reputation will not sufller 
by the Philosophy of Human Nature, which contains much in- 
teresting matter, and evinces great originality of mind, and deep 
thought 



Uematks on Mr. Aldridge^s Criticism on the London Pharma^ 
copoeia. By Richard Phillips, F. R. S., L. and E., and 
Lecturer on Chemistry at St. lliomas's Hospital. 

to the editoa of the dublin journal of bfbdical 80ierc& 

Sir, 

The Number of your Journal for March last, contains a 
notice of the London Pharmacopoeia, signed John Aldridge ; 
this performance, I presume, you inserted, in consequence of 
knowing that the author of it had enjoyed,^ at least, an 0{qx>r- 
tunity of being acquainted with the subject on which he has 
ventured to become a- critic* 

I trust to your candour for inserting sofiae remarks on this 
communication, relating chiefly to the chemical portions of it, 
observing, however, that the fantastic style of the author ex- 
hibits *^ the madness of poetry without the inspiration;'' — thus 



Mr. I%illips's Remarks oh Mr. Aldridge^s Criticism, 8fc. 110 

''wtboriied codes of pharmaceutic lore" {angUce pbarmaco- 
poeias) are " comets" which " spring forwaro* " like angels' 
visits" " to illuminate the medical horizon/' and in order that 
they may be duly scrutinized^ '^ every eye becomes armed with 
a philosophic tube/' &c. &c. &c. 

The effects which this critic's observations^ made with 
his armed eye, have produced upon him, appear to have been 
of the most varied descriptions ; and some of the operations to 
which he has been subjected in consequence of his prying, are 
such as few persons would willinglv submit to. Thus he is by 
turns amused and startled, dazzled and shocked, he laugns 
and loathes, smiles and is sick. 

To proceed^ however, with the chemical observations of tfiis 
critic : the first directions which incur his high displeasure^ are 
those for preparing nitrate of silver ; and afW translating aeidi 
nitriciAuiduTiciam, by half an ounce of nitric add, he exclaims^ 
'' all this as far as it goes is very correct ;" and it thus unfor- 
tunately happens that almost the only commendation which 
escapes the critic during his examination of the Pharmacoposia^ 
is bestowed upon a blunder, and one too of his own makings 
After thb happy commencement, he proceeds to give a long 
rigmarole account of how one Mr. Ferguson (of whom more 
anon) boys jEmr^ alver containing gold and copper, and how he 
separates the copper from the pure silver, by a process which is 
quite incredible ; and the critic evidently does not know, that 
in £ngland pure silver is free from copper. 

Tne critic (meaning by this term always Mr. John Ald- 
ridge) then asserts, that nitrate of silver <' does not become 
Ui^ened in the sunshine ;" if so, considerable pains have been 
taken by the authors of the Dublin Pharmacopoeia to pievenl 
the occurrence of what never liappens, I refer die critic to Dr» 
Barker's translation^ pp. 219, 221, 229, where nitrate of silver 
is directed to be kept in the dark, for the same reason as given 
by the London College; '^exposure to light," says Dr. Barker, 
'' contributes to give to the external surface of the cylinders of 
lunar caustic the deep purple or black hue." 

The critic then says — 

'* The test g[iven for the purity of nitrate of silver is perfectly fal- 
lacious, for when chloride of silver is thrown down from a concen* 
trated solution, by an excess of chloride of sodium, some o^ the pre* 
cipitate is always dissolved, and the supernatant liquid will conse** 
quently become discoloured by the sulphuretted hydrogen.'' 

Now this is a fair specimen of the critic's foul misrepresentation : 
he represents the College as ordering a concentrated solution 
of nitrate of silver to be used with excess of chloride of sodium, 
well knowing that no such directions are given. 



120 Bibliographic Notices. 

The operations which I shall next notice as incurring the cen- 
sure of this critic, are those for preparing protoxide of mercury ; 
and he has the hardihood to assert, that when chloride of mer- 
cury and lime-water were employed by him in the proportions 
directed by the College, and he applied heat to a portion of the 

f>roduct, " he was edified with the spectacle of five-sixths sub- 
iming in the form of protochloride oi mercury." I have made 
this experiment also, and in the mode which, I presume, the 
critic would have adopted had he performed it — that of at- 
tempting a failure. With this intention I shook a drachm of 
<;hIoride of mercury on a pint of lime water for less than a mi- 
nute, and immediately separated the precipitate by filtration ; 
the solution contained excess of lime, and aflter saturating this 
with nitric acid, I added nitrate of silver, and obtained 35.3 
grains of dry chloride; the whole quantity which the chloride of 
mercury could have yielded, would have been 36.3 grains, 
making no allowance for the error of experimenting. Admitting 
for a moment, that the critic did make the experiment, it is evi- 
dent that he put no faith in what he has stated to be the result 
of it ; for if he had, he would not have hesitated to declare that 
the College never tried whether the precipitate was soluble in 
acetic acid or not, instead of merely expressing a doubt of it. 
I have, however, no hesitation in asserting, that the critic never 
tried the College process at all, or did not obtain the results 
which he describes, and by which he was " edified." 

The critic then considers the directions for preparing acetic 
acid, which he instances as one of '^ those preparations, which 
have not the slightest use in medical practice." Even the critic 
himself never made an assertion more directly opposed by facts ; 
the acetic acid is used in preparing potasses acetas, plumbi 
acetaSy and oxytneL The process answers the purpose perfectly 
well, whereas that proposed by the critic is objectionable in 
every respect : the product is small in quantity, bad in quality, 
not very strong, two distillations are required, and the residue 
is with difficulty got out of the retort. 

The critic states, that when trisnitrate of bismuth is prepared 
as directed by the College, loss of metal is incurred, and he is 
certainly right in this respect, but so unused is his pen to fact, 
that it returns to fiction naturally and immediately; for the 
critic asserts, and without the slightest ground for it, that the 
trisnitrate of bismuth obtained by the College process is dis- 
coloured. 

A general charge is then brought by the critic against the 
College ; he tells us, that " new preparations are substituted 
for old ones, with the most reckless indifference to the opinions 
of the profession." To support this statement he adduces a pre- 



Mr. Phillips's Remarks on Mr. Aldridge*s Criticism, 8fc. 121 

paration which proves precisely the reverse, and it is exhibited 
with as great a parade and profusion of blunders, as ever were 
disulayed. The critic says, that in preparing what he calls the 
" old tartar of iron,'* by exposing iron to the action of bitartrate 
of potash, water and air, " the iron, influenced by induction fix)m 
the potassium, only acquired a proto-state of oxydation." From 
this statement it is evident that the critic is ignorant of the fact, 
that when iron is acted upon by bitartrate of potash and water, 
the oxygen which the metal first acquires is derived from the 
decomposition of the water, the hydrogen of which is evolved in 
the state of gas. I refer the reader to p. 254 of Dr. Barker's 
Translation, where he will find the true source of the oxygen 
mentioned. The critic says, that by the process just described, 
" there was obtained a permanent protosalt ;" thus an error in 
theory is naturally followed by a blunder as to fact. It is well 
known that tartanzed iron contains the sesquioxide, and not the 
protoxide of iron, the additional portion of oxygen being acquired 
from the air. Dr. Barker will again set the critic right if he will 
refer to p. 256 of his Translation, where he says, that when this 
preparation " is heated with potash nearly to ebullition, per- 
oxide of iron separates abundantly ;" thus our critic grossly 
misstates the source of the first portion of oxygen, and errs as 
greatly in denying the existence of the second. 

I have not, however, yet done with the " old tartar of iron," 
for the critic states, that " the whole preparation is worthy of 
notice, as a precious example of pharmaceutic legislation." 
Thus do arrogance and ignorance proceed together. The pro- 
cess is this : the ferri subcarbonas of the late Fliarmacopoeia, is 
replaced by the ferri sesquioxydum of the present ; they differ 
but little, except in name. A portion of tnis sulMstance is di- 
rected to be dissolved in hydrochloric acid, and to be precipi- 
tated from the solution by potash. The moist, hydrated, sesqui- 
oxide of iron thus obtained, is to be dissolved by boiling with 
bitartrate of potash in water; the critic, ignorant of the con- 
trol exerted oy cohesion over the solvent power of acids, 
thinks the dry sesquioxide of iron as well adapted for solution 
as the moist hydrate. The fact, however, is, that when the for- 
mer is used, bitartrate of potash takes up only about one-tenth 
of its weight ; whereas of the latter it dissolves nearly one-fourth. 
If the critic doubt the accuracy of my assertion, let him refer to 

E. 255 of Dr. Barker's Translation, where he will find it corro- 
orated in general terms. The present process, with slight al- 
teration, is taken from Soubeiran. 

Having stated that some preparations are improper, for 
reasons which he has assigned, the critic makes the sweeping 
declaration, that — 

VOL. XII. MO. 34. R 



122 Bibliographic Notices. 

'^ There are several which are objectionable ia everj point of 
view ; tartar emetic is made by boiling cream of tartar with crociu 
of antimony." 

And he then quotes a passage from Berzelius, which has 
nothing to do with the Jirocess; for I assert^ in direct contra- 
diction to the critic, that crocus of antimony is not used by the 
College. Crocus of antimony is prepared by mixing, defla- 
grating, and fluxing a mixture of equal weights of sesquisul- 
phuret of antimony and nitrate of potash, and the crocus is 
separated mechanically from the saline matter. In tlie College 
process the same ingredients are employed, mixed, however, 
with some hydrochloric acid : this mixture is merely defla- 
grated, and the saline admixture is separated by washing. In 
this way a preparation of antimony is obtained in a state of aggre- 
gation, much more favourable for solution than the crocus ob- 
tained by fusion, and which it is diflScult, also, perfectly to sepa- 
rate from the saline matter. I do not apprehend that the critic 
will be able to appreciate these advantages, but those who aro 
in the habit of making experiments otherwise than upon paper^ 
will be able to judge of them. 

Iodide of potassium is directed to be obtained by decom^.^ 
ix)sing the iodide of iron witli carbonate of potash; this, says the 
critic, is 

'^ Baup's process, which is objectionable from the difficulty of 
avoiding an excess of potash on the one hand, or of suffering a con- 
siderable loss on the other, from the precipitate of peroxide of iron 
carrying down a large quantity of iodine.*' 

Now Soubeiran, a well known French author, whose opinion, 
greatly, I have no doubt, to the surprise of the critic, I shall 
prefer to his, says " Le meilleur procfedfe pour obtenir ce sel 
est celui do Baup et Caillot.*** I assert that there is no danger 
of excess of potash when due care is taken ; and as to the 
precipitate of peroxide of iron of which the critic talks aboQt, 
there is none ; and so deplorably ignorant is he of the facts 
of the case, as to suppose that wlien proto-iodide of iron id 
decomposed by carbonate of potash, tlie precipitate obtained 
is sesquioxide, instead of proto-carbonate of iron. No waste 
of iodine, however, occurs from precipitation with the proto- 
carbonate of iron; I found that within l-160th of the whole 



• Pharmacic, tome ii. p. 374. 



Mr. Phillips's Remarks on Mr, Aldrulge's CrUiciam, ^c, \2.} 

theoretic quantity of carbonate of potash was required to pre- 
cipitate the iron in the state of proto-carbonate ; this would 
not have been the case if the iodine had been precipitated with 
it, instead of remaining to combine with the potassium of the 
carbonate of potash. 

"Our friend Mr. Ferguson," he who uses pure silver con- 
taining copper, I presume, is now cited by the critic, and for 
the purpose of exnibitin^ a series of chemical wonders. The 
passage wlilch contains them is not very long, and is much too 
curious to be abridged. 

" Mr. Ferguson," says the ciitic, *' has mentioned to us a process 
which be has been in the habit of pursning, which is simple, cheap, 
and most extraordinary : by boiling carbonate of potash, iodine, and 
iroo tumiogs together^ with a proper quantity of water, iodide of 
potassium is formed, carbonic acid and oxygen escaping with a 
violent effervescence, and the iron turnings remain untouched. This 
is most strange, and evidently belongs to the operations of catalysis, 
lately generalized by Berzelius/' 

Now by referring to Berzelius, it will be seen that this 
power is not exerted, when action can take place without it, 
and that the substance which produces the action remains 
nnchanged. We have then first to inquire, whether when 
iodine is heated in a solution of carbonate of potash, any action 
takes place between them, and any one who will try the expe- 
riment will find, as I did, that the iodine is dissolved, and the 
carbonate of potash decomposed with the evolution of carbonic 
acid gas; this combination, therefore, is not the result of catalysis. 
In order, however, to try what effect would be produced by the 
presence of iron, I boiled in a retort, 252 grains of iodine and 
56 of iron, in a solution of 177 grains of hydrated carbonate 
of potash. Carbonic acid gas was plentifully evolved, but not a 
particle of oxygen gas was evolved from the commencement to 
the close of the operation. Instead of the iron " remaining 
untouched," nearly one-half of it was converted into sesqnioxide. 
I pronounce, therefore, the whole statement respecting this 
** most extraordinary'* process to be a tissue of absurdities. 

With this critic every word is to be twisted as much as 
possible, in order that it may not mean what was intended : 
thus, as already shown, with respect to nitrate of silver, he 
represents the solution as directed to be concentrated, and 
chloride of sodium to be in excess, in order that they may not' 
produce the desired and described effect. So also when it is 
stated that iodide of potassium loses nothing when subjected 
to heat, according to the critic's version, the heat is to be of that 
degree which is well known to volatilize it. 



124 Bibliographic Notices. 

Chloride of barium is directed in the Pharmacopoeia to be 
prepared by decomposing carbonate of barytes with hydrochloric 
acia. •* Every one knows," says the critic, " how much more rare 
a mineral witherite is than heavy spar.'* The critic, however, does 
not appear to know, that in the same country as that in which 

Eure silver contains no copper, carbonate of barytes may be 
ought for about one penny per pound ; and if the sulphate cost 
nothing, it is more economical to employ the carbonate. 

^* Sulphate of potash/' says the critic, ** the College order to be 
made by roasting the supersalt remaining after the preparation of 
nitric acid, until the excess of acid is separated. This is a most 
awkward method ; besides that this residual salt is much sought after 
in the arts." 

More blunders : this salt is not much sought after in the 
arts, and very little of it could be had if it were, for the quan- 
tity made is extremely small ; the common residual sulphate, 
containing but a slisht excess of sulphuric acid, is preferred, 
whether mtended for alum making, or conversion into carbo- 
nate. Nothing can be more ridiculous than the mode of pre- 
paring sulphate of potash, propounded by this grave cntic, 
except the reasons for preferring it. It is too bad to copy. 

In the Pharmacopoeia iodide of mercury is ordered to be 
prepared by triturating together the requisite quantities of the 
ingredients, and adding a Tittle spirit during the operation. 

" We," the critic, '^ prepared some in this way, and mixing 
it with a solution of chloride of sodium, allowed it to filter ; upon 
the addition of nitrate of silver, a copious precipitate was thrown 
down, which was only ptfttially dissolved in water of ammonia. 
The iodide of mercury evidently contained a large quantity of 
biniodide." 

I have no doubt the critic will again think it strange, but I 
must again declare my preference of Soubeiran's opinion in 
favour of a process, to the experiments of so great a blunderer 
against it. Soubeiran says, that the process which the College 
has adopted is the best ; and in direct contradiction to the 
fallacious experiments of the critic, (if indeed he performed 
any,) I assert that the iodide of mercury, prepared as directed, 
was so perfect, that sulphurated hydrogen added to the solu- 
tion of common salt on which it was triturated, gave not the 
slightest precipitate. It was easy for the critic not to add 
sufficient ammonia to dissolve the chloride of silver which he 
precipitated, 

" An oxide of iron," continues the critic, " containing 
twelve or fifteen per cent, of proto-carbonate, has not hitherto 



Mr. Phillip's Remarks on Mr. ^Idridge's Criticism, 8fc, 125 

been considered as a very pure sample of sescjuioxide;" certainly 
not, but Mr. Ferguson would perhaps admit it to be so ; the 
sesquioxide of the Pharmacopoeia, contains, however, scarcely 
one per cent, of it ; but when it suits the purpose of this consis- 
tent cfitic, he can make a very different statement ; thus he 
says in another place, '^ that what is commonly called the 
precipitated carbonate of iron is itself a sesquioxide." 

I have now concluded my remarks on the lucubrations of the 
critic ; were I not disgusted with the occupation, I might greatly 
have extended mv observations, and have shown, by way of 
variety, the havoc he has committed with proper names, and with 
quotations ; but I am tired of wading through so contemptible a 
production, and which originated either in the inveterate igno- 
rance^ or wilful and malignant misrepresentation of its author. 

I am, Sir, 

Your obedient Servant^ 

R, Phillips. 



SCIENTIFIC INTELLIGENCE. 



GLEANINGS BT DR. BIGGER. 



Umbilical Hernia^ with escape of Urine through the unclosed 
Urachus. — The following case, observed by .Dr. Schmidt of Creiss- 
wald, is taken from the official reports of the Royal Medical College 
ofPomerania. 

In an infant, aged four weeks, who laboured tinder umbilical her- 
nia, a considerable discharge of fluid from the navel was observed. 
On examination it was found that the contents of the sac had passed 
about three quarters of an inch out pf the umbilicus ; at its summit 
there was an excoriated spot, about a quarter of ao inch in length, 
and a line in breadth, from which a considerable quantity of fluid 
dropped, having a strongly urinous smell. When the part was well 
dried the fluid was seen to ooze out distinctly from several points. 
The quantity was very considerable, for a pellet covered with leather, 
which had been applied over the part for twenty- four houns, was so 
thoroughly soaked, that it appeared as if rotten, and the compress 
and bandages were quite wet The natural passage for the urine was 
normal. The hernia was reduced, the excoriated spot covered with 
charpie, a smooth piece of cork laid over this and fastened with strips 
of adhesive plaster, a compress and bandage. After twenty-four 
hours, the exudation of fluid ceased, and at present the rupture is com- 
pletely gone, — Medinische Zeitung. 

Dipt her ite — ^The child H., 8 years old, of scrofulous habit, and 
who had already been suffering in her chest for three years, com- 
plained of loss of appetite, some pain in swallowing, and great weak- 
ness, occurring in consequence of catching cold in the latter end of 
June of this year; notwithstanding she continued to attend school. 
Her parents considered this illness as trifling, and first sent for me 
on the 2nd of July, as the ordinary household remedy for sore throat 
had been found of no avail. 

I found the child suffering much, and looking very pale, the eye 
heavy, the skin cold, respiration somewhat hurried, but in other res- 
pects unimpeded, and the voice not altered ; there was no cough ; the 
pulse quick and small ; the urine clear and a brilliant yellow ; and the 
evacuations free and of ordinary constitution ; her appetite had failed 
entirely, no great thirst, and for some nights the little girl had 
hardly had any sleep. It was only in the neighbourhood of the 



Scientific Intelligence. 127 

slightly enlarged sabmaxUlarj gland, that the neck was uneasy to 
the touch. From her nose and mouth a nauseous unfdeasant odour 
proceeded ; the tongue waa coveted with a yellow, mucus, and the 
hard and soft palates were paler than in. the natural condition ; the 
uvula was covered with a firmly attached* whitish-yellow, tenacious 
mucust the tonsils manifesdy enlarged, and covered with a white, 
]ardacious» fibrous . mass* which could be torn off by the fi>cceps, in 
small strips, which smelt very ofbnsively, without giving any pain. 
On the posterior wall of the pharynx were three insulated spots of the 
size of a pfenning, (about as large as an English silver four-penny- 
piece,) covered with a similar mass. By this the deglutition was 
rendered difficult, but not at all so much as is the case in angina. 

The evident cachectic condition of the patient, and tendency to 
putridity, forbade any violent antiphlogistic treatment, and deter- 
mined me to employ internally the aqua oxymuriatica, lemonade as 
drink, and to touch the parts affected with a camel's hair pencil 
dipped in muriatic acid and syrup of mulberries, and I ordered the 
neck to be rubbed with the linimentum ammoniae. 

On the 3rd of July the girl, after a sleepless night, was to alt 
appearance altered for the worse ; her eyes looked very heavy. Her 
pulse was quick, small, and weak, her respiration not difficult, but 
hurried; her voice somewhat rough; there was no cough, nor 
any sympathy of the larynx or trachea, but the lardacious coating^ 
had acquired a much -grei^ter circumference ; the uvula and the 
neighbouring parts to the soft palate, and the parts about the tonsils, 
particularly behind and beneath, were covered with a white exuda- 
tion ; two of the insulated spots at the back of the pharynx had 
become continuous : the Eustachian tube appeared also to be engaged, 
for the child complained of pain deeply aeated in the ear, particularly 
on opening the mouth. The offensive odour from Uie nose and 
mouth waa still worse than on the day before ; the swallowing of 
fluids. and aoft matters went on tolerably well. 

As what had been applied with the pencil had produced no 
change, I caused pyroligneous acid mixed with syrup to be applied' 
to the lardacious envelope, and in the intervals of its application, a 
gargle of aqua salvise, acidum muriaticum, and syrupus mororum, to 
boused. 

4th July. Great falling away ; features much changed ; visible 
emaciation ; cadaverous smell from the mouth ; and still greater 
extension of the lardy coating on every side. The Eustachian tubes 
were, to judge from the pain, still more and more affected, as also 
the poaterior openings of the nares. 

I now ordered a decoction of red bark with dilute sulphuric acid, 
to be taken internally, and a solution, first of two grains of nitrate of 
silver to the ounce of water, and afterwards, as that had produced 
no effect, three grains, to be applied locally. The child got, besides, 
meat soup with yolks of eggs, and a little red wine frequently. The 
greatest attention was paid to give her fresh air, and to keep her 
cool. 



128 Scientific Intelligence. 

On the 5th her condition was still more melancholy^ her general 
appearance yerj bad ; her pallid countenance fallen, and painfully 
drawn ; her complaints of pain in the inner ear and nose very great ; 
the voice hoarser, but the respiration and deglutition not very difficult ; 
the smell hardly endurable, so that the whidow was obliged to be 
kept constantly open, and chloride of lime to be exposed in plates; 
the pharynx as far as could be seen, the tonsils, uvula, soft palate, 
and inner surfaces of the cheeks, were covered with a thick, lardy 
concretion ; this had been rendered brownish by the lapis infemalis, 
and I succeeded in separating a piece with a forceps, of the size of 
a silver groschen, (about that of a British six-pence,) from the 
posterior wall of the pharynx, without caunng bleeding or pain. 
This false membrane was more than a line in thickness, of firm 
homogeneous consistency, and only to be torn with difficulty. No 
blood-vessels were discoverable in it. The place from which it was 
separated was of a bluish brown, very soft, and had evidently passed 
into a state of gangrene ; in the coiurse of the day many and smaller 
pieces of this membrane became detached and were thrown off; also 
in the thin, brownish green, and extremely offensive stools, were 
similar shreds to be seen. In the evening the greater part of the 
exudation had disappeared ; not so the foetor : I had added to the 
decoction of bark an infusion of the root of serpentaria, in small 
doses, and ordered the cavity of the mouth to be brushed with the 
solution of nitrate of silver : I had hopes of being able to arrest 
the progress of the gangrene in the parts freed from the exuda- 
tion* 

On the morning of the 6th the exudation which had been cast 
off, was renewed by a similar one ; the pain in the ears was unen- 
durable ; the breath, as before, offensive ; the respiration difficult, and 
the voice very weak and hoarse; the larynx and trachea were not 
painful, but to judge by the voice and respiration, they must have 
been covered by the exudation. Her strength had completely sunk, 
and her skin, particularly at the extremities, was cold ; pulse small, 
empty, and hardly to be counted ; her pale countenance bore the 
expression of the intensest suffering. 

I prescribed the decoct, cinchonae with infus. serpentarisB and 
acid, mur., and at intervals small doses of camphor, red wine, and 
sprinkling of the mouth and cavity of the jaws with aqua kreosoti. 
No means could now counteract^ or in the smallest degree impede, 
the course of this terrible disease ; it advanced irresistibly. 

In the evening this poor girl, constantly pointing to her head, 
and particularly to her ears, presented, being perfectly in her senses, 
a most miserable picture, with her pale, painfully-drawn visage, and 
her wearied and weak voice, which, however, she seldom employed ; 
at this time the atmosphere around her, despite of all antidotes, was 
absolutely pestiferous. Death, which was now wished for even by 
her parents, was every moment to be expected ; it did not arrive, 
however, till the following morning, after a miserable night. Un- 
fortunately I could not obtain an examination of the body. 



Scientific Intelligence. 129 

I wafi more fortunate in the cases of two brothers and a sister of 
this little -girl, whom- 1 had caused to be separated from her already 
on the 2nd of July, and for whom I had ordered acids and plentiful 
exercise in the open air. On visiting them duly, 1 found that on 
the 4th the two lurothers respectively of ^ve and six and a half years 
of age, had their tonsils swollen, and covered with the lardacious 
exudation, without pain m swallowing or inflammation having pre- 
ceded. Their breath was offensive, their tongues thickly overlaid 
with yellow mucus, and as signs of gastric derangement, there were 
present eructation, sickness, and sense of weight about the cardia. I 
g^ve them at once an emetic, and brushed the amygdalse strongly 
with the nitrate of silver. Afltor forty-eight hours a thick but soft 
eoating was thrown off from the tonsils; they were of a bright red, 
and had on their surface a thin coating of tc^erably healthy pus. 
By the internal use of the oxymuriatic acid water, and a gargle of 
alum dissolved in aqua melissss, the boys perfectiy recovered in 
eight days. Their sister, a girl of three years, taken ill two days after 
the boys, was treated in a similar manner and recovered. 

These four cases, which I had observed from the commencement, 
serve as confirmations of statements hitherto made, that exudation 
and ^se membrane can be formed with incredible rapidity, without 
any inflammation having preceded. Whether this dbease be con- 
tagious^ which the -taking ill. of the four children of the same family 
would appear to evidence, is a question which, from the small number 
of cases, I could not attempt to answer ; I would remark, however, that 
Bourgeois, who made observations on the diptheritis of the years 1827 
and 1828, in St Denis, as occurring in fifity-seven individuate, of whom 
&ve died under similar symptoms to those which I have detailed above, 
has declared his opinion that h is not oontagions^ — Mayer in Kreutz^ 
berg. 

The similitude of the cases deUdled above, to those described by 
Dr. Bewley, in the January Number, (No. XXIV.) of the year 183^, 
of ^its Journal, is most sviking, Almost in all points, and jalthough the 
treatment pursued by Dr. B. was much more active than that of 
Mayer, still the diptheritis held its course irresisUbly till death closed 
the frightful scene. 

Results of Re-vaccination in the Royal Prussian Army, in the 

Year 1836. 

In 1836, in the different divisions of the whole army, there 

were vaccinated 42,124 

Of this number there weco^xNisessing marks of former 
vaccination^ — 

Distinct, 32,635 

Indistinct, 6,645 

Residue having no marks at al]| 2,844 

VOL. xn. NO. 34. 8 . . 



130 Siuentific InielUyence. 

Took the iDfection, (being regularly examined during its cotirse,)-* 

Regularly, 18,136 

Irregularly, 9,940 

The vaccination was without effect in • . • 14,048 

Those in whom the vaccination had been ineffectivei and on 

whom it waa repeated, aucceaafully • . . • 1 1569 
Unaucceasfolly, . . . . . • . • 8,205 
By vaccination true pustules were produced — 

From 1 to 5 in 7,311 

6 to 10 in 5,647 

11 to 20 in 4,418 

21 to 30 in 760 

Amongst those successfully re- vaccinated in 1836, and earlier, there 

occurred in the course of that year — 

Of varicella . . . .14 cases. 
Of varioloid affections • • 8, 

Of true variola . • . . 
The military duties which the troops necessarily had toperfornp, 
and the want of vaccine matter, very often prevented re- vaccination 
during this year ; and, the same reason prevented the repetition of 
vaccination in those oases where re- vaccination had been unsuccess- 
ful. In by far the majority of cases the zeal of the military surgeons 
overcame those difficulties, as an inspection of this paper plainly 
shows. 

The vaccination succeeded, as in former years, as often as it was 
performed with fresh lymph from true vaccine pustules of children 
who had been vaccinated, and when the infection was transferred 
from arm to arm. In many divisions of the army, all the recruits 
were vaccinated in this manner. In others, however, this source 
was less attainable, and a greater or less portion of the men had to be 
vaccinated with lymph taken from genuine vaccme pustules, in aidults 
who had been vaccinated or re-vaccinated, and which pustules were 
runniDg a regular course, and thus the infection was carried from arm 
to arm. 

All the military surgeons who have tried the latter experiment for 
the propagation of cow-pock, attest with one voice that it has been 
attended with the best consequences, because in this way, equally 
good pustules, winch ran as regular a course, were produced, as in 
those cases in which the lymph for vaccination had been taken from 
the true vaccine pustules of children, and carried from arm to arm. 

Dr. Bonardin, military surgeon, from his observations during 
this and former years, is disposed to agree with the Wurtemburg phy- 
sicians, who give the preference to lymph taken from the true cow« 
pock of adults, to that taken from the pustules of vaccinated chil- 
dren. 

Dr. Hering, surgeon of battalion, as an' experiment, had vacci- 
nated a portion of the men appointed to be vaccinated, on one arm 
with lymph from children who had been vaccinated, and on the other 



Scientific Intelligence. 131 

arm, with that from the true vaccine piutule of adull8, and lias seen 
particularly favourable results, as these persons have had a remark- 
ably good and well-formed pock in consequence ; it was also good in 
those individuals vaccinated with lymph from children, but the pus- 
tules were better developed in those vaccinated with lymph taken (torn 
adults. 

Lymph preserved for infection has been used only here and there 
by the military surgeons during this year, when they were obliged to 
have recourse to it from the want of fresh vaccine lymph. Drs. 
Schwarz and Bonardin employed the lymph sent to them, on slips of 
wood for this purpose by Idv. Bremer, from the Cow-pock Institution 
here, with the very best consequences. 

In the application of this dry lymph, Dr. Schwarz wets it with a 
little sali?a, which he esteems particularly well adapted to make it 
fit for vaccination, without weakening its powers of propagation. 

Generally from twenty to thirty scratches were made this year^ 
divided between both arms. This number was seldom exceeded; and 
often, for want of vaccine lymph, we were obliged to be contented 
with a much smaller number. 

In the majority of cases the course and form of the pustules was 
regular, and there was nothing to distinguish them from the genuine 
pustule of vaccinated children. 

In those cases in which the inoculation produced numerous pus- 
tules, generally there was more or less swelling of the axillary glands, 
and sometimes there was a general feverish reaction, which particu- 
larly accompanied the stage of maturation. Occasionally during this 
year the remark was made, that vaccine pustules of the true form ap- 
peared one, two, or three days too late, but from that time they ful- 
filled their normal period, so that in such cases, the stage of repletion 
and suppuration came on, delayed by one, two, or three days. This 
species of late pock, in which the inflammatory halo first came on 
with swelling of the skin on the twelfth day after the inoculation, was 
observed very often in the 15th Regiment of Infantry ; and those late 
pustules, which were not regarded as true cow-pock by Dr. Bonarden, 
always remained small. Particularly numerous cases were seen by 
Eicliorn in the same year, in a form which he denominated ** modi- 
fied cow-pock ;" in them the disease developed itself very quickly, 
the pustules had an inflammatory redness surrounding them, and from 
the fifth day, only displayed a tubercular appearance. Although all 
those cases by Dr. Bonardin (the number in the 15th Regiment 
amounted to 327) had plainly pursued " an irregular course,** still he 
regards these modified vaccine pustules, with Eichorn, (an opinion suf- 
ficient! v bold,) as vaccine, inasmuch as none of those individuals were 
affected with natural smallpox. In some cases the course of the 
disease was complicated by other accompanying complaints. In one 
case in the 21st Regiment of Infantry, there was inflammation of the' 
lungs which occurred, and ran its course to recovery along with the • 
cow-pock : this came on after the inoculation, when twelve genuine 
pustules had been formed. In two other cases smallpox formed the 



/ 



132 Scientific Intelligence^ 

complication. In a recruit belonging to the same corpe, who bore 
evident marks of former vaccination, and who was now re-vaccinated 
successfully, true smallpox occurred. The pustules of both pocks 
ran their usual course in juxta-positiouy without being the least dis- 
turbed in their individual development The second case of this kind 
occurred in an individual belonging to the fusileer battalion of the 
3 1st Infantry, who on the 13th of May had been re* vaccinated, and in 
whom true smallpox occurred on the 22nd of May, after eighteen 
true pustules, the consequence of the vaccination, had appeared. 

A fusileer of the 3rd InfiEuitry Regiment, who had already in 
1835 been re- vaccinated successfully, was in 1836 once more sub* 
initted to re-vaccination, and even then with success ; in 1836 he had 
fifteen, and in 1 836, twenty-four true cow-pock pustules formed as a 
consequence of the re-vaccination. 

In this year also examples were not wanting of successful vacci- 
nation of persons who bore more or less manifest marks of smallpox 
having occurred at some former period. No case occurred of any 
person remarkably pitted with smallpox, having been a second time 
attacked with the natural smallpox Sn the army during the couiso 
of this year. In some cases it again occurred as in former expe- 
riences, that where the marks of earlier vaccination were very finoi 
large , round, and punctuated, that re- vaccination again produced very 
perfect and large pustules ; yet this occurred more frequently where 
two or three incisions had been practised, than where six or seven 
had been made. 

Other military surgeons, on the contrary, support the opposite 
opinion, inasmuch as they cannot regard manifest marks in those per- 
sons who have been re-vaccinated, amongst the causes why the re- 
vnccination should be without consequences. 

It is on account of this reason of the want of success in re-vacci- 
nation, that it was determined, in the 5th corps of the army, this 
year also, that those persons who had been a short time before re- 
vaccinated in the civil re- vaccination, instituted in the cities, if they 
cannot show the cicatrix of the pustule, should at their entry into 
the army again be re-vaccinated. However, cases of this kind occurred 
less frequently than in 1835, because the greater number of those 
persons brought attestations of re-vaccination having been performed 
on them. 

The present inspection shows, that from the,42,124 persons vacci- 
nated and re- vaccinated in 1836, 18,136 had genuine vaccine pustules 
running their regular course. This exceeds by much the results of 
former years. For example, in the year 18f33, 48,478 persons were 
vaccinated, of whom were 15,269 with success. In 1834, 44,454 
vaccinated, of whom 16,679 with success. In 1835, 39,192 were 
vaccinated, of whom 15,315 with success. The proportion- is almost 
this, that in — 

100 vaccinated in 1833 it succeeded in 30 
Do. do. 1834 do. 37 

Do. do. 1835 do. 39 

Do. do. 1836 do. in almost 43 



Scientific Intelligence* 133 

The iooculation produclog cow-pock running a regular course. 
This proportion has hitherto been increasing: whether it will in 
time to come proceed to any certain limit, the evidence of next year 
must tell. As above all this increasing proportion of successful in- 
oculation cannot be caused bj mere chance circumstances, so we 
may infer with probability, that there is an increasing capability for 
the reception of the vaccine infection in the yearly levies, with which, 
however, according to our former experiments, an increased predispo- 
sition for the contagion of smallpox must be received at the same 
time. The ever-increasing cases of smallpox in civil life, and the 
frequent attacks of it amongst the recruits, invariably just after their 
joining, appear to justify these inductions, which perhape m^ht be 
confirmed by the results, if bounds are not set to the further exten- 
sion of smallpox in the army by the re- vaccination of the recruitSi 
In this respect the re-vaccination in the army thia year, has given 
very satisfactory results. In 1836, of those who had been re-vacci- 
nated then or earlier, twenty- two were taken ill ; eight aflfected with 
varioloid disease, and fourteen with varicella ; and these dbeases in 
all ran a very mild and moderate course. In the 6th Curassiere, how-* 
ever, one case of genuine variola occurred, which terminated fatally ; 
this man bore evident marks of early vaccination, and had been revae- 
cinated, inasmuch as good pustules had formed as a consequence of 
re-vaccination : the man had rubbed these off afterwards, upon which 
a protracted and considerable suppurative inflammation in the arm 
came on. By this means the vaccine pustules were disturbed in their 
course, and could not be considered as vaccine ; wherefore this man 
is not included in the number of re-vaccinated with success. 

In the year 1836, 130 cases of natural smallpox (true, modified, 
and false pock) occurred in the army, amongst which the twenty-two 
mentioned above were included. In the majority it was varicella and 
varioloid disease of a mild nature, and only about one-fourth suffered 
from the true smallpox, in which, including the fatal cases men- 
tioned, nine deaths occurred, of which six happened in January. 

The greatest number of those taken ill of natural smallpox was 
soon after the junction of the new levies to the troops, before it was 
possible to submit them to re-vaccination. Some of them took ill already 
upon the march, or immediately after having reached their respec- 
tive troops. As soon as the revaccination of the recruits was over* 
the smallpox ceased to commit its ravages amongst the troops, with 
very few exceptions, notwithstanding that in many imperial garri- 
sons, as Mainz and Luxembourgh, smallpox prevailed to a greatei 
or less extent amongt the civilians, and was the cause of much fata- 
lity. In Weisenfels, and in the district around, already since the 
month of March, varioloid disease, and varicella, had prevailed 
amongst the inhabitants, when in the months of April and May, seven 
persons, all recruits, also of the 3 1st Regiment of Infantry, there in 
garrison, were attacked with the natural smallpox. The first, a re- 
cruit of the 12th company, took ill on the 22nJ of April of varicella, 



134 Scientific Intelligence. 

and four others of the same company quickly followed ; they all slept 
in the same room. Of these, three had varicella ; but in the fourth, 
true smallpox developed itself, which soon became confluent, and 
ended in death. On the 9th day of May, a man who was in the 
lazaretto on account of some wounds, was attacked with true small- 
pox, and soon after another, who had been already in hospital four- 
teen days, for a gastro- catarrhal fever, got varicella. 

The whole seven recruits had been vaccinated in their youth, as 
the cicatrioea upon their arms clearly showed ; re-vaccination had 
not, however, been performed on them, because the battalion sur- 
geon, Lohse, busied with the re-vaccination, which he had commenced 
in the month of April, had not yet been able to get to the 12th company, 
it being the last in order. When the re-vaccination had been per- 
fectly accomplished in the battalion, not a single man more became 
affected with smallpox. 

In 1636, one case of varicella was received from the 7th Corps, 
which occurred to a volunteer of the drd battalion of the 15th Regi- 
ment, Landwehr, who had been vaccinated in his youth, and again 
re- vaccinated in 1835 successfully. Not a man was taken ill of the 
natural smallpox, although it prevailed amongst the inhabitants of 
many garrisoned places in the neighbourhood of this corps of the 
army. 

In conclusion, it is worthy of remark, that this year more cases 
have occurred of individuals being taken ill off true or modified small- 
pox, on whom re-vaccination had been tried once or twice without 
effect. — Collected from the General Report of the Medical Staff, 
Berlin^ by Dr. Lohmeyer. 

Local Manifestations of Intermittent Fever — ^The wife of a 
citizen of this place (Muhlheim on the River Rhuhr) of a very deli- 
cate coni^itution, and hectic make, whose life had been preserved by 
an attention to diet which hope and the love of life, so common in 
the hectic, alone could render endurable. She had been for many 
years the subject of medical treatment, particularly in Spring and 
Autumn, at which times she felt herself oppressed with a dry cough, 
accompanied by stitches in the side. When the period of puberty 
arrived, she suffered much from irregular menstruation, which came 
on sometimes in too g^eat abundance, sometimes in too small a 
quantity, sometimes too early, and sometimes too late ; this impaired 
her strength very much, and caused congestion to the head and 
chest. 

The approach of her courses announced itself, for many years, by 
a painful prickling sensation in the right hip and right arm, to which 
a disabled condition of this side usually succeeded, but disappeared 
again on the appearance of the catamenia. 

These sufferings, to which she was now accustomed, returned in 
tlie Autumn of the year 1 836, with greater violence than ever, and 
continued throughout the entire winter, on account of difficult men- 



Scientific Intelligence. 135 

stniatioQ being superadded, and as jet (May, 1 837) that state has not 
been entirely removed. 

In the month of Febmary of this year, at the period when influ- 
enza raged, this woman was also attacked by it. After a few days 
the disease changed into a very extraordinary quotidian fever, which 
developed itself first in the left, and afterwards in the right arm. 
When the patient related, to me this unusual affection, I was not a 
little astonished at the occurrence, and that 1 might not be deceived, 
1 carefully put many questions to her, and caused her to tell her 
complaint many times over, before giving her my opinion. 

The paroxysm displayed itself in the following manner. In the 
morning, between 10 and 11 o'clock, soon after tiding her breakfast, 
she had an inclination to yawn frequently, followed by a trembling of 
the left arm ; by degrees the left arm, from the acromion to the finger 
points, became coUer and colder, vod at last as cold (as the patient 
expressed it) as if her arm had been immersed in cold water ; it also 
exhibited the appearance known by the aj^pellatlon of goose-skin, and 
the nails and fingers became blue. 

This local rigor was sometimes so violent, that the arm was some- 
times involuntarily jerked from one place to another: when it had 
lasted about an hour, it passed into the hot stage, which lasted fully 
two hours; after this an abundant perspiration followed, which ex- 
tended itself in a modified degree, some time after, over the entire 
body. The first two attacks of this local fever were slight; and not 
much noticed by the patient, but the third was so violent that she 
was greatly alarmed. 

I visited her at the feverish period, and saw the rigor, goose-skin, 
blue nails, and violent perspiration of the left arm ; no part of the rest 
of the body was in the slightest degree affected. To my great astonish- 
ment I found that there was no difference of tempe^ture in the two 
arms ; but the pulse displayed a very remarkable difference ; for whilst 
in the left it was 90, hart), wiry, and small, that in the right was 
only 80, and soA. In the hot stage there was no remarkable dif- 
ference in the pulses, and it was only in the sweating stage that 
that of the left wrist was accelerated, whilst that of the right con* 
tinned as in the preceding stages. In the forenoon the urine was 
natural, but in the afternoon it contained a lateritious deposit In 
other respects there was not anything in the eondiUon of the patient 
which seemed to depend in the slightest degree on the local fever in 
the arm. 

When this person had taken sulph. qoinss for two days in small 
doses the attack ceased, and she believed herself at length freed 
from her wearisome guest,* when after three days her right arm began 
to be affected with the fever as the left had been before, and these 
attacks were ^ve times repeated before they were entirely set 
aside by the use of quinine. Now, however, there occurred towards 
three o'clock in the afternoon, after a slight rigor, with transient 
flushes of heat over the whole body, and particularly a burning in the 



136 Scientific Intelligence* 

hands, a geaflfal enfeebling pertpiFation, which was, however, gra- 
dually removed by the employment of adequately powerful means ; 
and evidently these were rather lo be considered as symptoms of the 
former cachectic condition of the patient, than as having any real con- 
nexion with the recently occurring local' fever. 

The fever described bears with it all the recognizable symptoms 
of a local fever, without exhibiting itself in any: way as a masked 
fever. Thai there is an^ evident diffsrence between a local and a 
masked fever seems put beyond all doubt by the case described.* — 
Dr. J. H. Leonbard, MuhVinm 4m the, Ruhr. 

Sweating of Blood from the Feet in Tertian Fever. — Dr. 
Kaminsky baa commiinicated a very carious case of th» affsction. 

The fether of a girl in the country, who was suffering from ter-* 
tian fever, was alarmed, not oidy at the fever, but particularly at 
a transudation of blood from the feet from one day to another. On 
an accurate inqutry, it appesTed'that the girl, who, from description, 
had been of a strong and plethoric habit of body, had never men* 
struated ; the blood &wed in considerable quantity on the days of the 
fever, with the 'accession' of the hot stage, from both feet, from open- 
ings caused as if by leeoh bkes, and again ceased gpradually after the 
paroxysm waa past. By an appropriate treatment, particularly by the 
employment of quina, which this physician gave in combination 
with carbonate of magnesia, carbonic acid, and rhubarb, the fever 
soon disappeared, and dong with it the bleeding at the feet. Aflter 
pediluvia bad been employed for some time, menstruation appeared.— 
From the Provincial Returns of Health of the Royal College of 
Medicine^ Pomerania. 

Frictiome toith Lard^ by Dr. Hoffmann. — The newly prescribed 
frictiens wi^' lard do good service, notonly in profuse and colliquative 
perspirations, (pkrticulariy at the upper part of the body,) but have 
also been found of the greatest use to other hectic subjects, whose 
skins were not particularly active, as in various kinds of asthma.*— 
Medieinieche Zleitung in Preussen. 



. i 



On Toothach from Caries^ 6y Trosehel.— This author has fol- 
lowed up some observations made by him last year in a Prussian Me*- 
dical Jooreal, Att which he endeavoured to prove that the violent pain 
which occurs in caries of the teeth is not caused by the laying bare 
of the nerve ; and that oaries, if unaccompanied by any other ailment, 
is in most cases free from pain. There aro exceptions, however, to 
this rule which are not uncommon* 



* Whilst eagtged tranilating thii article, Dr. Graves mentioned fo roe, that a 
nearly panrallel case had just occurred to him in another disease, vis. jaundice, in 
which the yellow tint had alone appeared on the hands, all the other parts of the 
body being as fair as usual. 



Scientific Intellhjence. 137 

We find ordinarily two or more cartons teeth together, of which 
^very oflen one gives great pain, and the others which are much moro 
injured, and in an apparently worse condition, give no paini Despite 
-of all palliatives, and all possible attention in the avoidance of cold, 
the pain often lasts whole weeks with increasing or decreasing vio- 
lence ; there is congestion and repeated swelling of the face, sleep 
and appetite are banished, and even the good constitution of the suf- 
ferer begins to be affected. After the tooth, the author of all thia 
suffering, has been drawn^ all complaints cease, and the paUent soon 
recovers. 

If the extracted tooth bo now broken in two, or what is better, 
sawed longitudinally through the centre, we find that from the 
carious part, which is often very distant from the nucleus, there ex- 
tends a black or brown streak into the cavity of the tooth where the 
nerve lies. Sometimes this streak is not very distinctly marked, and 
in this part the substance of the tooth is only a little less white, dul- 
ler, and more pellucid than the surrounding structure. This change of 
colour occurs on this account, because that the canals in the substance 
of the tooth, which lie in layers close one behind another, and pass from 
the circumference to the centre, are permeated with pus, (according 
to the examinations of Purkinje, Valentin, Gurlt, and Muller;) they 
"are denominated by the last mentioned author, " caniculi chalico« 
phori." In caries of the crown of the tooth, the phosphate of lime 
which is contained in these canals is absorbed, and during the suppu-^ 
ration, the carious matter infiltrates still farther from the base of 
the alMcess into these little pores : then not only the white colour is 
lost, but the nucleus of the tooth (the nerve of) becomes affected, 
ttnd this causes the most intolerable pain. 

Every dentbt of observation has seen those dark streaks which 
pass to the nerve; the little canals can, however, only be seen un- 
der the microscope, and then only on thin sections of the tooth pre- 
t>ared on a grinding stone. 

It is only from very acrid applications, and such as for a period 
paralyse the nerve, that any alleviation is to be obtained from the 
torture one suffers, and which arises in the manner we have described. 
Even the application of the actual cautery to the carious hollgw, has 
no lasting effects, and the extraction of the tooth remains as the t)nly 
resource. 

Treatment of Scabies^ hy Dr. N. Meyer of Minden.— On account 
iif the great quantity of scabies which has come before us, we feel 
called upon t^ give the results of the treatment pursued on the plan 
recommended by Dr. Vesin for the cure of this disgusting disease ; 
we do this the more willingly, as this plan appears to us to insure 
quick, cheap, and safe results. 

The treatment made use of in the hospital is as follows. The 
patient is placed in a chamber appropriated to scabies, which in' 
winter as well as summer is &ept at a temperature equal to 28 to 30 
of Reaumur; he is put in a warm bath, in which his whole body is 

VOL. XII. NO. 34. T 



138 Scientific Intelligenctu 

rubbed with black 8oap and coan« woollen dotha, ao atroogly, that all 
the pustulea which have appeared are rubbed off. He ia then put ta 
bed between two blankets, wrapped up in a thick woollen doak ; here 
he remains for twelre hours, and then, for the first time, he is rubbed 
prer the whole body, near the stove, with the following ointment— > 

]^ Sulphuris Depurati ^i. 

Pulv. Radicis Helebori albi 3ii. 

Kali Nitrici gr. x. 

Saponis nigri Ji. 

Adipis suilli ^iij. 

M. ut fiat unguentum. 
After having rubbed in this ointment, the patient lays himself 
similarly wrapped up as before in his bed, and after twelve hours 
inore a second rubbing in is performed, and again after twelve hours 
a third and last rubbiog in is accomplished. After this, having lain 
for another twelve hours, he is put into a warm bath, in which every 
trace of the ointment is carefully removed, by rubbing him with 
))lack soap and woollen cloths. 

The patient, now cured, is provided with clean linen and purified 
clothes, and taken to another room. In summer he may be per* 
mitted to depart after an interval of forty-eight hours, being now 
perfectly free from itch ; in winter it would be prudent to prepare 
him, by keeping him in a moderately warm room for two days, be- 
fore allowing him to go into the cold air. 

It is clear that this method of curing scabies in a short time, and 
without iojury to the health, howsoever simple it may be, is yet attended 
with great difficulty in its application in certain private houses : but 
in all large cities where the number of operatives affected with this 
disease is great, and where quickness of cure at a small cost, 
renders an itch institution a desirable object, very little difficulty will 
be found. 

But since for some years, in many districts, the itch has been 
observed to spread very generally, and by an imperfect treatment of 
fome cases only, constantly continues, so in such districts the insti* 
tutiug of a proper place with baths and rooms easily warmed, as well as 
procuring other slight matters which might be necessary, could not 
pieet with much opposition, and we should hope that from i^ strik- 
ing propriety, that wheresoever the extension of the disease renders 
it necessary, such institutions may be formed and put into action. 

It were desirable that such arrangements, as well as th« con- 
ducting of the curative process, should be undertaken alone by persons 
perfectly understanding them : we would remark also, that without 
perfect cleansing of the beds, linen, and clothes used by each patient, 
^fter he is cured, and above all a regard for cleanliness, a new in- 
fection is always to be feared. A slight tax on those itcbly disposed 
families who make use of the institution, wonld very soon cover the 
expenses. 

Institutions of this kind in the cities, at a very small expense, 
might give opportunity of treatment to itch patients in the neigh- 
bouring districts. 



Scienti^ Intelligence. 139 

The institution here requires for undertaking the cure of a 
patient placed therein, two ReichBthaler, (6s. 6d. British;) for this he 
has diet, baths, medicine, and medical treatment. 

Of the persons affected with scahies in this institution, twelve 
individuals, cured in the manner described in two and four days, wer6 
detained a much longer time for medical inspection, all remained welt, 
and not one suffered a relapse. 

Treatment qf Scabies by simple mechanical Means^ from 
Berlin Medical Times, — The administration fot hospital affairs 
has caused the treatment recommended bj Staff-Surgeon Dr. Kohler 
to be employed from June to the end of December, on all the patient* 
affected with scabies in the Charit^. This treatment is purely me- 
chanical, and consiejts simply in frictions with a mixture of finely 
powderedl^brick dust, (Ziegelmehl.) 

The result of this treatment has been, that in the time mentioned 
678 patients have been discharged from the institution, who have 
remamed there a period of 1 0,576 days, which allows eighteen days 
and a half on an average for the cure of each patient. 

Now as in the ordinary treatment pursued at an earlier period 
in the Charite, by means of frictions with an ointment composed of 
green soap and sulphur ointment, on the average fourteen days were 
necessary for cure, and as it has occurred frequently in the seven 
months before specified, tht^t persons wha appeared perfectly well 
when discharged, have again returned affected with itch, which has 
not been remarked as of sach frequent occurrence during the period 
when the sulphur ointment was employed ; therefore, for the interest 
of the patients, the hospital conductors have thought fit to abstain 
from the further use of mere mechanical means; and again to return 
to the more successful method, that of rubbing in the sulphur oint^ 
ment before mentioned. 

Union of the Scalp by the first Intention^ when nearly the whole 
pf it had been detached. (Communicated by Dr. Brach in Nen»- 
tadt.) — In July of this year, (1836,) a young and robust slater 
19 years of age, fell from a roof in Neustadt, on account of a sca^ 
fold which he was fastening giving way : he struck first with his 
head upon the roof, and slid along the tiles, and then fell with his 
body turned sidewards upon old building wood and rafters upon the 
ground. There he lay without motion, and was thence borne to his 
dwelling, which was near. 

I arrived about a quarter of an hour after the accident. The 
wounded man had during this time come to himself ag^in; he 
sighed and whimpered, and breathed tolerably tranquil : his pnlse 
was small and frequent, and at times irregular ; his consciousness 
was very much disturbed, he spoke nonsense, and either answered 
wrongly the questions put to him, or did not answer at all. His 
countenance was pale, and from time to time vomiting occurred. 



140 Scientific Intelligence. 

There were do coitusions on his body, except, upon his left ^ide, on 
the hip and arm on which he had fallen; his head on the contrary 
presented a wound of immense circumference ; the whole scalp was 
severed from the middle of the frontal bone, right and left, to both 
^ars, and then torn loose in its whole extent as far backwards as 
the occipital protuberance, so that the whole scalp could be turned 
back, almost like a night cap ; very nearly the whole of the scull 
was laid bare, and thus looked like the scull of a subject, prepared 
for the removal of the brain by a circular incision with the saw. 
Besides this, there was a long tear in the middle of the scalp, which 
passed nearly to the vertex. It was also somewhat torn on the 
jiides. In many places the pericranium was shaved off with the 
scalp nearly a quarter of an inch square, but there was no discover- 
able injury done to the bones of the sculh When I drew the scalp 
forward again, it adapted itself in all points to its old situation, and 
remained very well placed, as we may say, of itself. 

I now began to clear the immense woimd of hair, fragments of 
slate, and such like substances, of which a great quantity was 
concealed in the wound, and which was truly a laborious task, 
and with the shaving of the head lasted a long time. We were 
obliged often to give restoratives to the wounded man, on account of 
the frequent vomitings and faintings with which he was affected. 
After the requisite cleansing of the wound had been effected, I laid 
the flaps again in situ, united them with long straps of sticking- 
plaster, laid a simple compress upon it, and secured the whole by* 
means of a cloth brought behind and under the chin. Internally, I 
gave him an infusion of arnica, with sulphate of soda. 

The bloody suture seemed to me unnecessary, as every thing ap- 
peared to lie as neatly as possible with the dry suture, compress, and 
bandag^. However I considered that in so considerable a wound 
of the head, as soon as the present symptoms of concussion had 
passed, there certainly would be an inflammatory reaction of the 
brain, and that then the patient, in a fit of delirium, might tear off all 
the bandages; at the same time I thought that the bloody suture 
would not be able to prevent this misfortune, wherefore I remained 
satisfied with the dry suture. Cold applications I did not think 
indicated either, because they would loosen the bandages, and on 
tbeir firmness all chance of this immense flap becoming united by 
the first intention, depended. How could a remedy for such exposure 
of the whole scull be expected without union of the flap ? If the 
flap did not heal what would be the consequence of such an exposure 
of the whole scull ? and how could this immense mass of skin be 
replaced ? On this account I confined myself to the simple means I 
have mentioned, endeavoured to keep the patient in the greatest 
quietude, caused him to be carefully watched, the chamber to be 
darkened, all excitement and disturbance to be avoided, and had 
idetermined on the first trace of inflammatory reaction setting in, to 
meet it by venesection, and internal remedies. These symptoms 
shewed themselves the next day towards the afternoon. The patient 



Scienfijlc Intelligence. 1 4 1 

became uDeasy { th'e face, lately pale as that of a corpse, became 
flushed; he complained of a burning sensation over the whole bead, 
was feverishly hot in the entire body, and again raved more dis-) 
tractedly than he had done in the forenoon, although . from time to 
time during the night he had slept tolerably ; the vomiting abo, 
which had ceateed towards morning, began again. ' The tongue 
was coated with yellow fur ; the patient insisted on getting out of 
bed, and was detained there with the greatest difficulty ; his pulse 
was tolerably full, strong, and hard. The bandage yet sat very well, 
on which account no change was made. Rest and sleep followed in 
an hour after venesection. Two grains of calomel were now admi-9 
nistered in place of the arnica and sulphate of soda, which caused 
several watery stools during the night. 

The next morning the patient was remarkably tranquil, and a 
considerable remission of fever had occurred, yet from time to time 
there was the same distracted raving ; he had no recollection of his 
fall from the roof. In the afternoon a new exacerbation of the fevet 
came on, with great restlessness, and increased delirium. After 
again bleeding him to nearly twelve ounces, he became again much 
more tranquil. 

Matters went on the same way on the third day, when a pound of 
blood was abstracted. Internally he was given tartrate of kali 
dissolved in chamomile tea, with a strong addition of watery tincture 
of rhubarb. 

On the fifth day, towards morning, a warm perspiration came ou| 
over the whole body, after which the heat and restlessness entirely 
left him, and the pulse lost its abnormal hardness and frequency. 
The vomiting had entirely ceased two days before, and the tongue 
had cleaned in great part. The bandage sat perfectly well; the 
Slicking plaster still adhered firmly, and the whole scalp was applied 
accurately to the scull. The great anterior g^h in the skin, which 
passed from the brow on both sides to the ears, suppurated in some 
points ; pressure upon the head gave some pain, but not much, and 
the sensation of burning in the head had entirely ceased. 

Similar internal treatment was still pursued. On the sixth day 
he was able to get out of bed without assistance ; his tongue was 
cleaner ; appetite again natural ; delirium had ceased ; he was very 
ibrgetful, and found difficulty in expressing his thoughts. 

On the eighth day from the accident I removed the bandages en« 
tirely, and this whole, immense flap was found to be perfectly united io 
the identically same situation to the pericranium from which it had 
been detached, and it was alone the anterior wound from the fore« 
head over the temples, which suppurated in some places, but in the 
third week it had perfectly healed in all points, and recovered its 
<K>lour. 

Forgetfulness and wandering of mind lasted still four. week*. 
}a the fifth week the invalid, despite of my prohibition, again ventured 
4ipon the roof. 
/ Nine weeks after this accident he Mi again along with anotbef 



142 Scientific Intelligence* 

•liter from a iK>of^ on account of a scaffold again breaking loose ; tlio 
other broke bis arm ; be fell more lockil j, and only receired a sligbt 
cootusion on tbe leg ; after tbjs be remained unalterably constant in 
bis passion foralating. 

Communicatien of Animal Poisons to Man,'^^A, strong peasant 
M C ■, stuck the fore-finger of the right hand, which was free 

Irom. any injuries, into the throat of a goose which had dropped 
down suddenly, (which goose unfortunately was not exapuned accu- 
rately,) in order to convince herself if any foreign body might bo 
contained therein, which was choakiog the animal. 

Soon after this, in other respects fruitless examination, this 
woman felt violent darting pains in the finger, which soon extended 
over the whole hand ; very g^at swelling also soon occurred. Surgeon 
Kalusky of Cronstadt, two days after this occurrence, found the hand 
and the whole of the right arm considerably swollen ; the swelling 
was doughy to the feel ; the index finger was of an enormous size, 
and the skin of a bluish red, and from it very violent and irritating 
pangs ext^ded to the arm-pit. Her general health was at the same 
time much affected ; she suffered from weariness, vertigo, and faint- 
ings* The surgeon compared the state of the patient with that of 
those persons in 4iot climates who have been bitten by the viper. 
Having ipternally administered musk, and employed externally the 
compound spirit of angelica, the woman got perfectly weU in a com-» 
paratively short time* 

To this occurrence I would add as a supplement :— 

The Communication of an Herpetic Poison from Calves, 
vrhicfa I have perceived to be no unfrequent occurrence now that my 
Blind was directed to the subject ; and I have seen, since having com*- 
mmicated the above, ag^n three persons infected after this manner. 
From the cases which have become known to me hitherto, either by 
oKaminations after . death, or through the communications of other 
observers, I -think I may conclude, that — 

1st As in* the rot affecting highbred and common sheep, so that 
the mange is of a much more inveterate nature in high bred calvea 
itban in the calves of our common cattle. That 

2nd. The communication of this mang^ poison can occur both 
frona the oommon breed of calves of tlie country, and from those 
4rooght from abroad ; and 

3rd. That the mange communicated to men from high bred calves 
is more inveterate and difficult of cure, than that communicated by 
the young -of th^ common cattle of the county. — Meyer in Creutx* 

Dt. Kolley has remarked, at Preisewitz, that male and female 
senranis who have had the care of horses and homed cattle, affected 
sdth mange, have been attacked with a similar eruption on the arms, 
face, and breast, combined with remarkable constitutionai effecte. 
She «S6 -of a solution of the chloride of lime cured the eruption both 
in men and beasts in the space of four weeks. 



Scientific Intelligence. }4^ 

OfAntimonial Suppositories as a Mean of restoring the Hamof^ 
rhoidal Flux. — The physicians of past ages, have, perhaps, too mack 
exaggerated the importance of heemorrhoids in the scale of pathological 
phenomena, while those of our own time are fallen into the contrarj 
extreme. 

It cannot he denied that the suppression of the hemorrhoidal flux, 
when hahitualy may he productive of general disorders among men, 
Inmost as serions as the suppression of the menses in women. More- 
over, it is as generally admitted, that with certain persons who have, 
not only regularly, but at indeterminate periods, a draining or hsemor^ 
l-boidal flux, the existence of this pathological condition is attended 
with a state of general good health ; although it may remain for a 
long time uncertain and variable, provided the hcemorrhoids do not 
manifest themselves as soon as usual. Observation shows also, that 
persons whd have had hsBmorrhoids for a long time, suffer generally, 
if this flux entirely ceases. And it often happens that there is a caU 
for its restoration. 

Many means have been advised to effect this indication. The 
warm local baths, mustard foot baths, leeches to the part, suction ap- 
plied to the lower part of the large intestines, purgatives, and copi^ 
ping glasses to the part. Of all the means which we have made use 
of, only one has succeeded in any satisfactory manner. This is the 
application of cupping glasses. This mean was entirely forgotten^ 
when a student of the Medical Faculty of Paris restored it to honour, 
and I am able to bear witness to its effects on him. 

He had had haemorrhoids till the a^ of twenty years, and always 
enjoyed good health. This flux now ceased, when he became subject to 
violent pains in the stomach, and continual disorders of the digestive 
organs. He consulted M. Andral, while attending the Hospital de la 
Pltii, and this physician made use of every mean advised by authors 
A>r restoring this flux. Nothing succeeded, and the disease remained 
stationary. The young patient then conceived the idea of applying a 
cupping glass to the part. During this application the circumference 
of the anus enveloped the hemorrhoidal tumours, which for eight 
days were swollen and painful. From this time his health was re- 
established. A month after this he experienced a slight return of 
gastric disorder ; and one day, while attending my visit to the hospi- 
tal, he spoke to me of the relief which he had obtained the previous 
month from the sufferings which he now beg^ to feel ag^in, and of- 
fered to let me witness the prompt appearance of the hesmorrhoids 
under the operation of the cupping glass. I accepted the invitation 
with alacrity, and at the same time I placed him upon the bed of one 
of the patients, and in the presence of more than forty physicians and 
students, I applied a cupping glass to the fundament, A minute did 
not elapse when the tumours made their appearance, and becoming 
•nited, they acquired the size of a small pigeon's egg ten minutes 
after the application of the instrument. The same means were made 
use of the following day, and the haemorrhoidal flux continued for a 
week, and wa^ followed by a cessation of the disorders of the stomach. 



144 Sctentific Intelligence. 

M. Andral also saw this young; physician, and can testify with me to 
the great rapidity with which the tnmours became swollen. 

After this I had only one opportunity of locally applying cup- 
ping glasses for recalling hsemorrhoidal flux. This was with a female 
afflicted with erratic rheumatism, which to me appeared to be caused 
by the suppression of habitual hasmorrhoidal flux. I sn<5ceeded ia 
puffing up the htemorrhoidal vessels by means of the copping glass ; 
but the tumours disappeared soon after the application of the instru- 
ment. What prevents my using this remedy more frequently is this : 
in the first place, patients^ especially women, have a great aversion to 
it ; secondly, I have conceived that a much more simple remedy, 
and the employment of which can never be the subject of serious ob- 
jection, will answer the same end, I allude to antimonial supposi- 
tories. 

As I had never succeeded with aloetic suppositories, I thought by 
substituting in the place of aloes one of the most energetic irritants 
I might attain the desired end. Now, tartrate of antimony, applied 
locally to the skin or mucous membrane, creates an inflammatory 
action very powerful and persisting, I therefore preferred this article. 
i mix with a drachm of butter or lard, from two to six grains of tar- 
trate of antimony. The suppository, being introduced within the 
sphincter of the anus, melts quickly, and the tartrate of antimony re-» 
maining in contact with the mucous membrane, excites a lively local 
irritation, a species of tenesmus^ as a necessary consequence. When 
the suppository contains only a grain, or half a grain of the tartar, it 
tan be retained for twelve hours without the 'necessity of going to 
Stool ; but when a greater quantity of it is made use of, the patient 
experiences a beat, at first slight, but afterwards scorching, and at- 
tended with painful pulsations at the part ; there is a necessity of fre- 
quently going to stool. The arterial pulsations increase at the same 
time that the circumference of the anus protrudes, and pustules, simi- 
tar to those excited by tartar emetic on the skin, now appear ; bluish 
tumours arise, hard and painful, permitting occasionally a large quan- 
tity of blood to transude. These are the true haemorrhoidal tumours, 
perf^^ctly evident with those who have had them already, and only 
apparent with those who have not had them. 

I have often advised this remedy, in consultation, in my private 
practice, and in the hospital. I have taken notes of only six patients 
who ha?e uesd it. With five of these the hsemorrhoidal flux was re- 
established ; in the sixth, who had never had hsBmorrhoidal tumours, 
I was unable to excite them. I will briefly relate these six cases, as 
they aflford some practical interest. 

Case I. — A man 36 years of age, had an haemorrhoidal flux until 
his thirty-fourth year. The flux appeared at irregular periods four or 
five times a year. At each tkne it lasted at least five days. He took 
a cold which at first seemed to be of little importance; but during the 
Continuance of the cold, hsemoptysis came on, and the hemorrhoids 
disappeared. The cold still continued, and the haemoptysis was re- 
peated, and lasted for several days without any means being able to 



Scientific IntelUgence. 145 

arrested it. Soon nfter this symptoroB of phthisis pulmonalis were 
manifested, and he concluded to enter the Hospital Dieu. 

There was considerable emaciation, and slight hectic fever ; re- 
sonance less at the upper part of the right lung, both before and 
behind ; murmur in inspiration scarcely perceptible — in expiration it 
was very strong ; slight broncophony ; rale snb-crepi tan t, suflSciently 
frequent ; some humid crackling and a trace of pectoriloquy ; expecto- 
ration muco-puriform, and often streaked with blood ; but little appe- 
tite. These were the symptoms of tubercles beginning to be formed 
in the lung. Nevertheless, having regard to the suppression of the 
hflsmorrhoids, I conceived that there might exist in the respiratory 
organs a point to which there was an undue flow of blood, similar to 
that which lately existed in the pelvis. I determined on recalling the 
hssmorrhoids. I made an application of a suppository of tart, antim. 
It excited a glow of heat around the anus, and the following night, 
large hsemorrhoidal tumours appeared, which continued six days, 
and discharged abimdantly. A great amelioration of the thoracic 
symptoms took place ; the expectoration immediately ceased to be 
bloody; and was much diminished, so that five days afterwards, he 
coughed but little, and respired almost as strong as usual. Soon after 
this the piles appeared without solicitation, and the threatening 
symptoms which had been manifested in the breast were completely 
dissipated. Indeed, I do not imagine that I cured phthisis pulmo* 
nalis, but merely an obstinate congestion of the lung, which probably 
would have ended in inducing tubercles. 

Oase II. — A cook, aged 50 years, entered the Hospital Dieu, in 
order to be treated for a chronic disease of the stomach. This man 
stated, that three years previous to his entering the hospital, he had 
been afflicted with piles, which returned every month, and which at 
that time became suppressed. Since then he had lost his appetite, the' 
little which he did eat gave rise to pains in his stomach, attended 
with' obstinate constipation. 

He had made use of local bloodlettings, opiates, laxatives, mag- 
nesia, &c., in vain. I thought that the hoemorrhoidal flux ought 
first to be re-established if possible. For this purpose 1 applied a sup- 
pository containing the tart, antim. The first suppository gave rise 
to a diarrhcDaand teti^smiis, but no tumour. The next day another 
suppository, containing three grains of the tartrate antimony to the 
drachm, (a little stronger than the previous one,) was made Use of.' 
This caused a very sharp pain at the anus, and on the third day we 
found that very large and painful hsemorrhoidal tumours had arisen. 
These tumours remained swollen for several days, without applying 
any suppository, but did not discharge. His health was improved, 
but was not completely established. A month after this, a new ap- 
plication of the suppository caused the piles to discharge, and at the 
same time his stools became bloody. This discharge continued for 
six days and then ceased. The health of the patient became much" 
impri^ved, and after using the waters of Vichy for three weeks, his 
cure became confirmed. I have not since seen the two patients whose 
VOL. XIT, NO. 34. u 



146 Si^tific Intelligence. 

casea I have jii»t related, so Ihal I am unable to say what their prweol 
state of health is. 

Casb III.— a woman, aged 40 years, was attad^ed with obsti- 
nate erratic rhenmatism. I imagined that by provoking hsBmorrhoids# 
she might obtain some relief, I therefore applied two antimonial sup^ 
positories. The tumours appeared ; continued two days, and then di»< 
appeared ; but the rheumatism was not mitigated. This case, appa- 
rently of no consequence, proves that haemorrhoids can be excited in 
those who have never had them. 

Case IV. — A young man, aged 30 years, contracted a gooorrhoBa, 
which was treated and cured with emollients and balsams. Soon 
after this he experienced all the symptoms of syphilis. The velum 
palati was destroyed with a large ulcer ; the nasal fossa, and even the 
larynx, were not exempt from alteration. The prot iodide of mer- 
cury, bathing with a solution of corrosive sublimate, and local caute* 
rization with nitrate of silver improved the character of these disor- 
ders. As the patient had formerly had bleeding piles, which returned 
many times yearly, but had disappeared during the last year, I ap« 
plied for two days in succession the antimonial suppositories. The 
piles appeared again and discharged abundantly ; but there was no 
abatement of the disease. 

Casb V. — In September, 1835, while attending the hospital, a 
patient, aged 45 years, came under my care. He had a very serioua 
attack of sub- acute hepatitis. Hepatic enlargement was very distinct, 
and there also existed an effusion of the peritoneum and the cellular 
tissue of the pelvic organs. As he had a high fever, I took blood from 
the arm, but without any relief. I also applied leeches to the right 
hypocondrium, and over the whole seat of disease, but without any 
mitigation of the malady. The patient had had in the course of his life 
three or four attadcs of piles. Knowing how much importance modem 
practitioners attach to hsemorrhoids, especially in diseases of the 
liver, I determined on exciting in the pelvic vessels a derivation which 
might be salutary. The application of an antimonial suppository 
produced on the seccmd day very painful hsemorrhoidal tumours, 
which discharged much blood. Nevertheless, the disease increased 
in a frightful manner and the patient died. 

Case VI. — M. R.,,aged 52 years, during his own life had been 
subject to bleedings from the nose which returned many times during 
the month, particularly in the spring. His father, who died at eighty- 
two years of age, was subject during his life to hsemorrhoids, which 
flowed regularly every month. 

The epistaxis had now been suppressed for three years, during 
which time he was subject to affections of the head two or three times 
a year, especially in the spring. He also had a species of cerebral 
excitation similar to that which marks thecommencement of drunken- 
ness. The application of leeches to the part moderated these symp- 
toms considerably, but they soon returned and gave much uneasiness^ 
The regularity of the hremorrhoids in the father caused me to think 
that a monthly congestion in the rectum would be of great service. 



SdenUfic InieUig^nce. 147 

Darmg one year, M. R. applied for three days every month an anti- 
menial aappoaitory. Thia application excited a violent irritation, and 
an eruption which evidently did not differ from the ordinary eruption 
produced by antimony. The inflammation lasted only a few days. 

Although hsBmorrhoids, properly so called, did not supervene, the 
eerebral affsctions have not given any uneasiness, and hie whole health 
would have continued to improve, if the patient had patience to con- 
tinue the use of the means. 

Let U8 recapitulate the facta contained in this brief account. An- 
timonial suppositories in six cases, in order to provoke haemorrhoids. 
In five the hsemorrhoids appeared two days after the employment of 
the means. Four were truly haomorrhoidal ; one was not. in the four 
first, the eruption whs persisting ; in the other it lasted only two days. 
In one of the patients it was impossible to produce the tumours. Of. 
the six patients, three were cured, probably in consequence of the ap- 
pearance of the flux. One of these three might have been cured,, 
although the hasmorrhoidal tumours, properly so called, were not pro^ 
duced. Three experienced no alleviation, ^though the hasmorrhoids 
were reproduced easily and abundantly. It would be too hasty to draw 
general conclusions from so small a number of cases, I wish only to 
make known to the faculty a therapeutic mean, by which they can 
fulfil indications which may sometimes be presented to their notice.-^ 
Journal de Connaisances Medico^ ChirurgicaUs, 

On the Uterine Syphon^Sfc, by Professor Montain of Lyons. — It 
not unfrequently occurs'that accouchement becomes difficult from the 
rigidity and dryness of the foetal head and uterine passages, consequent 
either on the too early escape of the amniotic fluid, or on a state of irri- 
tation, such as to deprive this fluid of its usual lubricating properties. 
The pains then diminish, the parts become swollen and inflamed^ and de- 
livery is distressingly procrastinated. Having observed a considerable 
number of such cases both in my service at the Chariti of Lyons, and 
HiprivaCe practice, 1 have resorted to the following expedient, with uni-^ 
form success. The operation is perfectly simple, and this is perhaps 
the reason it has hitherto escaped the attention of practitioners; but 
its simplicity cannot diminish its value, since its usefulness is fully 
eetablished. 

The instrument is a silver canula, from five to six inches long, 
fliUghtly curved, terminated by a flattened oval extremity, very thin, 
and perforated on both surfaces by a great number of small holes; the 
other extremity is constructed so as to receive the end of the canula of 
an ordinary syringe. 

This instrument, which I denominate an uterine syphon^ is well 
oiled, and directed so as to introduce the flattened extremity between 
the foetal head and the uterus, which may be done without difficulty 
and without pain, and, with a syringe, tepid olive oil is injected so as 
anoint the head and passages. The canula is successively carried 
around the head, the passages soon become soft and yielding, and the 
bead escapes without diflkuTty. 



1 48 . Scientific InteUigemce^ 

I might relate a great number of cases on this subject, for the ac- 
couchements susceptibleof relief by the syphon are of frequent occur- 
rence. I will at present give but two. 

Case I. — Mrs. L. had been in labour more than twenty-four 
hours, when I was requested in consultation with her physician. The 
pains were severe, but the waters had long since escaped. I proposed 
injectipns by mean's of the syphon^ but yielded to the desire of the at- 
tending physician, who preferred the forceps. The application of 
these, however, was attempted in vain ; injections were used, and 
the head immediately passed out. 

Ca s e II. — Mrs. C. had strong pains, and was extremely nervous ; 
the waters had passed off three days before ; the parts were dry and 
apparently inflamed ; according to the midwife, the pains had been 
strong for several hours, but had effected no change in the position of 
the child. Injections were made around the child's head, and it almost 
immediately came through with the greatest ease. — Gazette Medicate* 

M. Montain also recommends the injection, by means of the 
syphon, of a tincture of ergot into the uterus, as preferable in many 
instances to its administration by the stomach. The preparation he 
uses is made by digesting half an ounce of ergot in three or four 
ounces of alcohol, and keeping the bottle well stopped. Of this, one 
or two table-spoonfuls may be mixed wiih tepid water, and thrown into 
the neck of the uterus ; to be repeated if necessary. If the action be. 
too powerful, it can be moderated by sedative, and, subsequently, by 
demulcent injections. M. Montain relates two cases in which this 
medication was signally successful. 

On the Typhous Fever, which occurred at Phitadetphia in the 
Spring and Summer o/1836; illustrated by Clinical Observations 
at the Philadelphia Hospital ; showing the Distinction between this 
Form of Disease and Dothinenteritis, or the Typhoid Fever, with. 
Alteration of the Follicles of the small Intestine. — By W.W. Ger- 
hard, M. D., one of the Physicians to the Hospital. [We have 
thought it right to make copious extracts from a paper, published by 
Doctor Gerhard, on Typhus, in the American Journal of Medical 
Sciences last February. We have omitted all the cases and dissec- 
tions detailed in the original paper, and which furnish ample evidence 
that Doctor Gerhard has arrived at his conclusion by means of an in- 
duction sufficiently extensive and accurate ; and we rejoice to find that 
bis inquiries have been materially guided by papers originally published 
in this Journal.] 

During a residence of two or three years at Paris, I had studied 
with great care the pathology and treatment of the disease usually 
termed, in the French Hospitals, typhoid fever, or typhoid affection^ 
There is another designation for it, founded on its anatomical cha«, 
racters, and therefore more directly in accordance with modern medi- 
cal nomenclature ; it is dothinenteritis. This variety of fever, which 
is identical with the disease termed typhus mitior or nervous fever, is 
frequent at Paris, and is almost the only fever which can be said to 
be endemic there. Intermittent and remittent fevers are lively seen 



Scientific Intelligence. 149 

except ainoDgst those iodividuaU who had already contracted some 
form of these diseases io the malarious districts of France. Some 
slight feverS) attended with a whitish or yellow tongue, and gastric 
symptoms, occasionally occur ; they scarcely assume the form of a 
fixed disease, and usuadly disappear under a very simple treatment. 

These fevers were the only ones known at Paris for some years 
past; but in 1813-14) there occurred a severe epidemic fever, cha- 
racterized by extreme prostration, and strongly marked cerebral 
symptoms. This epidemic was first noticed amongst the troops who 
returned from Napoleon*s unsuccessful campaigns in Germany and the 
east of France ; it afterwards spread amongst the inhabitants of Paris 
and other large cities, and was every where extremely fatal. No ac- 
curate description of this fever is on record, although it was witnessed 
by several of the most distinguished French physicians. Some of 
these, more especially Louis and Chomel, are inclined to consider it 
as identical with the prevailing dothinenteritis, but their opinion is 
probably erroneous, and the disease, as far as we know, should be 
classed among the forms of continued fever, disting^bhed by the 
terms typhus, typhus gravior, petechial or spotted fever, &c. 

There are, however, complete histories of the typhoid fever or ty- 
phoid affection, or dothinenteritis, (all names belonging to one dis- 
ease.) It is one of the most frequent and the most severe acute affec* 
tions observed at Paris, and has been studied with extreme accuracy^ 
more especially by Louis and Chomel, who have both published admi- 
rable descriptions of it. The work of Dr. Louis is especially interest- 
ing and is a model in its kind ; he has analyzed the symptoms and 
pathological phenomena of the fever so accurately and fully, as to sur- 
pass any other description of individual diseases. The typhoid fever 
was placed by this work of Dr. Louis, in the same relation to other 
fevers that pneumenia holds in reference to the affections of the chest 
They are both so well studied, and their symptoms are so well known^ 
that they serve as types with which other less thoroughly understood: 
affections may be compared. 

It affords us, then, great advantages in the investigation of the 
history of fevers, to begin with the typhoid, as the best known of these 
affections. Assuming this disease as the basis of our investigations, 
one great point is gained, and much ^eater certainty can be given to 
our ulterior researches, if we compare the symptoms of any fever which 
is little known and imperfectly described, with those of the typhoid 
fever, or dothinenteritis, as it is now frequently called from its anato- 
mical lesion. 

This inquiry was in accordance with a desire which I had long 
cherished, of investigating the most common fevers in the middle states 
of America, where, from our geographical position, we witness the 
fevers observed at the northern, and occasionally those of the sonthera 
states. The commercial relations of Philadelphia are so frequent with 
the whole southern coast of the United States, and the passage to the 
north so rapid in the summer and autumnal months, that we receive 
into our hospitals a considerable number of patients taken ill on th^ 



ISO Scientific InteUigehc^. 

coast of North Carolina, Viiginiay and even Alabama and Lousiana; 
There are, therefore, few places where such a study could be pnrsiied 
to more advantage than at Philadelphia. Daring the last three years 
of a constant connexion with our largest hospitids, either as resident 
or attending physician, I have not lost sight of this object of study, 
and I have already published in the American Journal for the year 
1835, some cases of the dothinenteritis as well as the remittent and 
intermittent fevers. 

Dothinenteritis is by no means a rare disease at Philadelphia, al* 
Uiough less common than at Paris. In the essay alluded to I esta- 
blished the identity of the anatomical characters and of the symptoms 
of the fever occurring at Philadelphia, with that observed at Paris. I 
also showed that the patients were chiefly those who had resided but 
a short time at Philadelphia, and that they were taken ill on ship-board , 
or under some other circumstances causing an abrupt change of food 
and habits of life. They were also young persons, but few having 
passed the age of twenty-five years. Both these condititions of age 
and change of habit are to be observed to be essential to the develop- 
ment of typhoid fever at Paris. 

Having once established the complete identity of a fever which is 
so common at Paris and so well described, with a similar affection not 
nnfrequently met with at Philadelphia, I examined the pathological 
phenomena of our remittent and intermittent fevers of the severe ma- 
lignant character so frequently observed along the southern coast, and 
sometimes occurring in those malarious parts of the country which 
are situated within a short distance of Philadelphia. In all these 
fevers the glands of Peyer, as well as the other intestinal follicles, were 
found perfectly healthy ; the large intestine was occasionally but not 
constantly diseased, while the stomach, and to a still greater degree 
the liver and spleen were invariably found in a morbid condition. If 
the fever proved fatal in the course of the first fortnight, the liver and 
spleen were softened as well as enlarged ; but if the disease assumed 
a more chronic form, the viscera were hardened as well as hypercro- 
pkied. The latter state was the first stage of these chronic lesions 
which are formed in the livers of patients long affected with remit- 
tents or intermittents, and which continue tho)ughout the course of 
the ascites, which is so common -a consequence of these diseases. I 
made numerous examinations of the bodies of patients who died of the 
same variety of malignant remittent and intermittent during the sum- 
mer of 1835, and still more frequently in the epidemic of 1836, a year 
in which these diseases have been unusually fatal throoghout the 
southern states. The results of these late examinations have con- 
firmed those already obtained, and showed that the follicles of the small 
intestine are free from lesions, and that the anatomical character of the 
disease is to be looked for in the spleen, liver, and stomach. 

The bilious and yellow fevers are probably referrible to the same 
class as the malignant remittents, but in yellow fever the disor- 
ganization seems to be most extensive in the stomach, whence arise 
the bkdc vomit, which forms a characteristic symptom of the 



Scient^ Intelligence. 151 

disease. Bilious fever, or, in other words, the remittent fever 
attended with unosaal alteration of the liver and a disordered secre- 
lion of bile, is common with us. Yellow (ever is rare, and occurs 
in an epidemic form at such long intervals, that I have seen but few 
cases of it. 

The typhous fever, which is so common throughout the British 
dominions, especially in Ireland, is not attended with ulceration or 
other lesion of the glands of Peyer.* From the account of the 
lesions presented by nuMt of the writers upon the subject, it would 
seem that there is no constant anatomical lesion, but that the lungs 
present traces of disease more frequently than any other organ. My 
own observation of this variety of fever was: limited to the examina- 
tion of the fever patients under the caro of the late Dr. Ghregory of 
the Edinbuiigh infirmary. This observation was not sufficiently long 
or accurate to enable me to do more than refer to those physicians 
who have enjoyed extended facilities for the study of this aflection. 
The lesion of the glands of Peyer is now well known to the British 
physicians, but an error frequently committed by them is that they 
regard this affection (dothinenteritis) as a mere complication of their 
ordinary typhus, or a modified form of it. At least I do not at this 
moment recollect any one who has clearly stated that the two die* 
eases are always distinct, before the publication of a note in the 
Dublin Journal, by Dr. Lombard of Greneva, (Sept. 1836.) 

It is not possible to set this matter at rest, unless a series of accu-' 
rate histories of typhus with detailed s3rmptoms and pathological 
lesions should be published by British f^ysicians. With the aid 
of a statement of this kind, such a com|mrison might be made as to 
set the points of difference between the ordinary British or Irish 
typhus and the dethinenteritis of France m their true light From 
the information we possess, we should conjecture that the two dis- 
eases are widely and entirely different in symptoms, anatomical cha- 
racters, treatment, and mode of transmission. But the British typhus 
seems to us to be identical with the disease which forms the subject 
of the present memoir, and is apparently the same affection which is 
variously designated typhus gravior, ship fever, jail fever, camp 
fever ; sometimes petechial or spotted fever. The term typhus mitior 
of the older writers seems nearly synonymous with that of typhoid 
fever or dothinenteritis of the French Physicians. 

In America there have occurred several epidemics of fever more 
or less similar in their nature to the British typhus. Some of these 
were confined to the New England States, where they were often 
known under the name of spotted fever, and are described by Norths 
Hale, and others. Other epidemic diseases of a similar type extended 
to a larger district of country, and overran a considerable portion 
of the Middle States, causing extensive ravages both in town and 



* I metn that this letioa, wbea it occurs, it eieftly accidental, or a complies* 
tioD not oeeurring in the ordinary coarse of the disease. 



152 Scientific Intelligence. 

country. It was of epidemics of this kind that many distingnished* 
physicians of Philadelphia perished in different years, amongst them 
were the professors of the University, Rush, Wistar, and Dorsey. 
No distinct history of the typhous fevers which prevailed at Philadel- 
phia at different periods between the years 1812 and 1820 is on re-* 
cord. 1 mean such an account of the disease as makes its diag- 
nosis so clear that there can be no danger of confounding it with 
other analogous affections. The fever was well studied by the 
physicians who practised at that time, but the habit of analyzing 
symptoms had not been introduced, and their experience, however 
valuable to themselves, was in a gp'eat degree lost for their successors. 
These remarks are so true, that although an eminent physician 
of Philadelphia pronounced the epidemic of 1836 to be the same 
as that of 1812 and succeeding years, another distinguished medical 
gentleman who was not familiar by his own experience with the 
former disease, considered them as distinct affections, and that 
the one which first occurred was a low grade of pulmonary inflamma^ 
tion. 

That the fevers were really identical, was proven by the opinion 
of Dr. Parrish, one of the most experienced physicians of Philadel- 
phia, who practised very extensively amongst all classes of inhabi- 
tants in the winter of 1812-13, and was remarkably successful in 
his treatment of the prevailing fever. He saw some of the cases 
at the Philadelphia Hospital in 1 836, before the disease had extended 
to the wealthier classes, and immediately recognized its true cha* 
racter. 

For a period of at least ten years there has been no epidemic of 
this nature at Philadelphia. In the year 1827, a large number of 
Irish emigrants were ill of a typhoid fever, with ulceration of the 
small intestines, which was probably dothinenteritis, and during 
several successive years there were more or less extensive epidemics 
of remittent and intermittent fevers, occurring in the neighbourhood 
of the city, but not often extending into the central parts of the 
town. Occasionally, sporadic cases of fever of a comatose or 
typhoid character woo Id occur, but these cases were nearly always 
either some form of malignant remittent, or else they occurred 
during the winter months, and were complicated with pneumonia. 
The inflammation of the lungs then appeared as the first stage in the 
disease, which afterwards assumed those cerebral symptoms of stupor 
and feebleness, which have procured for it the designation of 
pneumonia typhoides. These cases I often witnessed while resi- 
dent physician of the Alms-house Infirmary during the years 
1828-30. 

At Boston, in the year 1833, there was an epidemic dothinen- 
teritis of extreme gravity^ and unusually fatal. This fever was well 
studied by the late James Jackson, jun., and other physicians, and 
was proven by them to be identical in symptoms and pathological 
lesions with the typhoid fever of Paris. Some of the physicians 
of that city are inclined to regard their former epidemics as of this 



Scientific Intelligence^ 158 

nfttore, but this opinion seems to us more than doubtful. Since the 
epidemic, the typhoid fever is there a common sporadic disease^ 
hither more frequent apparently than at Philadelphia. 

In the winter of 1 635-36, there was an unusual number of oases 
6f gangrene of the lungs at the Philadelphia Hospital, and but few of 
decided pneumonia. Several cases of dothinenteritis occurred in the 
autumn, but there were few afterwards. During the winter, a fona 
of fever not commonly met with at the hospitals, was observed from 
time to time. It was characterized by pungent burning heat of the . 
skin, dusky aspect of the countenance, subsultus^ delirium^ with great 
stupor and prostration ; but there was no diarrhoea, and but few other 
liymptome referrible to the alimentary canal. It was the disease 
which afterwards appeared as an epidemic. At first it was^not weH 
lulderstood by us, was sometimes confounded with bronchitis or 
pneumonia typhoides, from the complication of pulmonary disease 
with the symptoms of the fever. These cases recovered under the 
<ise of a mild stimulating and supporting treatment, with one except 
tion, in which death ensued from sloughi^ of the sacrum and 
gangrene of the lungs. 

In the early part of the month of March, the admissions for the 
fever were more numerous. They attracted' the greater attention 
from their occurring in groups of several from the same house, and 
almost all coming from a particular neighbourhood. Amongst the 
very first admitted were seven negroes, the entire population of a 
cellar in the lower part of the city. The symptoms varied but little 
in the seven cases, and upon an examination of two of the number 
who died, no lesion of sufficient importance to account for the symp« 
toms could be detected. 

As soon as these patients were admitted I resolved to note with 
care the pathological lesions presented by the bodies of most of those 
Who should die of the fever, examine its symptoms and ascertain the 
influence of therapeutic agents upon it. This research was com- 
menced with a view to obtain more precise notions as to the charac- 
ter of an epidemic which has probably more than once appeared in 
America, and seems to be endemic in Great Britain and Ireland. It 
waff especially desirable to ascertain if there was a real fundamental 
difference between the form of disease which prevailed this year 
and the dothinenteritis which is always to be met with in Ame- 
rica, as a sporadic afilBction. My friend and colleague. Dr. Pen- 
nock, had charge of one-half the medical wards of the Philadelphia 
Hospital; his observations were conducted at the same time with 
my own, but the autopsies and the examination of doubtful cases 
were always made in the presence of both of us. Dr. Pennock 
noted a large number of cases, and has given me the privilege of 
adding his collections to my own. They are the more valuable 
from the familiar knowledge which he obtained of the dothinenteritis 
in the wards of La Pitie at Paris. Our inquiries were conducted so 
much in concert, and our opinions as to the symptoms and treatment 
of the fever were so often compared together, that this memoir is 

VOL. XII. NO. 34. X 



154 Scientific Intelligence. 

in most reBpects the expreasion of the results obtained by oar joint 
labours. 

A portion of the cases were treated by Dr. Pancoast ; of these I 
have no notes excepting such as were obtained from the registers 
of the wards; they were chiefly admitted towards the close of the 
epidemic season, when we had already procured a large mass of 
materials.* 

Many of the observations are deficient in the history of the early 
symptoms, as the patients at their entrance into the hospital often did 
not retain intelligence enough to recollect the previous symptoms of 
iheir disease. The autopsies were always made with great care, 
more particularly the examination of the small intestines ; but the 
weight of occupation and the ennui of recording results which varied 
so little among themselves, caused us to neglect committing some of 
them to paper. We have, however, noted in detail a very large 
number, showing the nature of the lesions ; and we always took great 
care to remark the diseased or healthy state of the organs. We are 
quite sure that nothing of importance escaped us, and, above all, that 
the condition of the follicles of the small intestine was carefully 
ascertained. Our mass of facts is so considerable, that many im- 
portant questions will be solved by them in relation to the history of 
this form of continued fever. They will clear up many questions 
relative to the disease ; for although few cases are as complete as we 
could have desired, the information which is wanting in one case may 
be gathered from others ; none are deficient in all the particulars, or 
fail to give a tolerably exact statement of the symptoms at one period 
or other of the disease. 

In our investigations, we availed ourselves of the opportunities we 
possessed to inquire into the pathological anatomy, the symptoms, the 
mode of communication, and the treatment of this fever, which had 
not been witnessed at Philadelphia for some years, even if it were 
the same disease as that of former epidemics. At each step of this 
progress, I shall compare the facts before us with those relating to the 
history of the typhoid fever, or dothinenteritis, and when the symp- 
toms differ, it will be easy to draw the line of distinction between two 
diseases, differing in their treatment, symptoms, duration, and patho- 
logical lesions. 

There is some confusion in the designation of these fevers, but it 
is not my intention to enter upon a discussion of their nomenclature. 
It is sufficient to state that in using the terms typhus, typhous fever, 
typhus gravior, spotted or petechial fever, I mean that disease which 



* TheM inquiries were greatly promoted by the zeal and industry of the resi- 
dent physicians of the hospital, who were all much interested in the examioatioa 
of the disease, and untiring in their e/Torts to relieve the sufTering of patients 
who always required much more than ordinary care. In the rotation of service 
the most arduous duty fell to the lot of Drs. Bush, Stille, Patterson, Elmer, 
Frisby, and Johnson, of whom the two last mentioned were themselves attacked 
with fever. 



Scientific Intelligence. 155 

forms the subject of this memoir, and that by the terms tjphos 
mitior, typhoid fever, or dothioenteritis, I mean the disease described 
by Louis, Chomel, &c., and attended with a lesion of the glands of 
Peyer. 

The number of cases admitted with typhus, was 214. Of this 
number there were 120 men and 94 women. A few cases who were at 
the same time in the wards, and already under treatment for other 
diseases, are not Included, although they were afterwards affected 
with the prevailing epidemic, bnt their names on the register present 
onfy the disease for which they had been admitted. The whole nam* 
ber of cases is, threrefore, from 230 to 250. A large majority of the 
214 patients were negroes or mulattoes, there were 147 people of 
colour and 67 whites. The disease first appeared in the former class 
of patients, and always prevailed more extensively amongst them than 
the whites who were Irving in the same part of the town, and exposed 
nearly to the same causes of disease. 

The patients were taken with the fever in various parts of the city 
and neighbouring districts, but by much the g^atest number came 
from that part of the town which extends from Lombard-street to a 
little below Shippen, and from Fifth to Eighth streets ; this small but 
crowded district became almost an infected suburb. Within these 
limits the poorest and most intemperate of the inhabitants of Philadel- 
phia reside. It is the St. Giles or the Faubourg Saint Marcel of Phila- 
delphia. The filthiest and most crowded alleys offered the greatest 
proportion of patients. Thus, Small-street and St. M ary's-street, with 
the numerous courts and alleys running from them, contained many 
more sick than other streets inhabited by a population nearly as poor 
and intemperate, but less crowded. The different streets were not 
infected at the same time, thus the earliest patients were taken ill in 
Shippen and in Small streets, while St. M ary's-street, which furnish- 
ed an immense number of patients, was comparatively free from in- 
fection until a month afterwards. The disease appeared very soon 
in the prison (now taken down) in Arch-street, but as the inmates of 
the prison come in great part from the infected district, it is possible 
that the disease may have been introduced by those who were admit- 
ted while labouring under it. Towards the close of the epidemic, 
patients were admitted in considerable numbers from some of the 
streets in the Northern Liberties, and throughout its wliole course 
there were scattering cases from different parts of the city, and a few 
from the country, where there were no others ill in the house from 
which the patient had come. But few cases, however, occurred in the 
central parts of the town, where the inhabitants are generally in easy 
circumstances, and comfortably fed and lodged. 

Classes of Persons affected. — The first patients were almost ex- 
clusively from the poorest and most intemperate class of people, chiefly 
day-labourers. Such was the case with most of the blacks, especially 
the men, who were almost without exception in the habit of drinking . 
freely of ardent spirits. The women were without fixed occupations, 
or were servants out of place. As the disease extended to the differ- 



156 Scient^ Intelligence* 

eot parts of the city, people of various occupations were afiiected, 
amongst them there was one respectable physician, who died of the 
fever. The extension of the disease to those in easy circumstances^ 
was shown in the practice of several eminent physicians of Philadel- 
phia ; they had not seen a case until the fever had prevailed some 
months at the hospital, although they afterwards met with it in their 
private practice. 

Mode of Propagation of the Disease. — ^The origin of the disease i3 
as unknown as that of most epidemics ; according to the general rule, 
it attacked those who were sunk in poverty and intemperance, and 
huddled together in con6ned apartments. . It also appeared at differ- 
ent and remote points, some miles distant from the focus of infection, 
without the possibility of tracing any direct communication between 
those already attacked. There was, thus, a general cause, which ex<F 
tended its influence throughout the vicinity of Philadelphia. But, 
besides the epidemic cause, from which the greater number of cases 
seemed to arise, the fever was evidently propagated in a consider* 
able proportion of patients by direct coptagion. Those who entered 
at an early period of the epidemic came in groups together, some from 
the prison, whole families from the same room or the same house* 
About that time I made a careful inspection of the district as one of 
a committee of the Board of Health, and in some instances we found 
houses completely vacated, the tenants being either dead or at the 
hospitals. In other cases, the whole or a large proportion of the in- 
habitants of a room were ill. It was rare to meet with a severe case 
without seeing others in the same house. 

The evidence of contagion at the Philadelphia Hospital was more 
direct and conclusive. Three of the principal nurses, and about a 
dozen assistant nurses, besides a number of patients ill with various 
diseases, were taken with the fever. The three principal nurses be- 
longed, two to the wards for blacks, where there were the greatest 
number of fever patients, and the third to a ward for whites, where 
there were several cases. There was only one nurse of a ward in 
which many of the patients were collected, who escaped, but several 
of his assistants and patients were taken ill. Two of the resident 
physicians in attendance upon the same ward, where the patients were 
most numerous, were also severely ill with the fever. On the other 
hand, no nurse from the part of the hospital where there were but few 
or no typhous cases, suffered, and the number of patients taken ill in 
the surgical or lunatic wards was very small, not exceeding six in 
number. The wards in which fever pe^tients were placed did not 
contain more than a third or a fourth of the population of the hos- 
pital, yet the number of cases originating in them after the first in- 
troduction of the disease was at least four times as great as in al} the 
other parts of the building. The Alms-house and House of Employ- 
ment, which are separated from the hospital by a space of at leas( 
forty feet at the nearest points, furnished five or six cafes, proba* 
Uy not more than the same number of poor in any other part of the 
nei hbourhood would have done. 



Scientific Intelligence. 157 

The proportion of attendants upon the eick who suffered was in exact 
relation to the numher of fever patients in the ward; thus in the wards 
for blacks, (both men and woipen,) and in the men's medical. No. 1, 
scarce! J an assistant escaped. In the other medical wards a few were 
taken ill, and in the surgical and lunatic wards all the nurses escaped. 
The matter of the contagion, be it what it may, was generally mingled 
with the air, but sometimes seemed to be combined with the pungent 
hot sweat of the patients. In some cases the contagion was evidently 
direct from body to body. This was established by the evidence of 
a nurse and an assistant, both persons of intelligence, and, from their 
familiarity with the disease, quite free from fear. The nurse was shaving 
a man, who died in a few hours after his entrance, he inhaled his 
breath, which had a nauseous taste, and in an hour afterwards was 
taken with nausea, cephalalgia, and ringing of the ears. From that 
moment the attack of fever began, and assumed a severe character. 
The assistant was supporting another patient who died soon after- 
wards, he felt the pungent sweat upon his skin, and was taken imme- 
diately with the symptoms of typhus.* The wards in which the 
fever patients were placed, were large and well ventilated. We 
were at first disinclined to believe that the disease would prove con- 
tagious, but as soon as the fact was clearly proven, measures were 
taken to remove the patients not yet affected from most of these 
wards, and, if it had continued for a longer period, an efficient local 
quarantine would have been adopted. Dead bodies either did not 
communicate the contagion or its influence was easily counteracted 
by favourable circumstances. Both Dr. Pennock and myself, and 
several of the resident physicians, were engaged nearly every day 
during the most intense prevalence of the disease in making long and 
laborious anatomical investigations, without suffering from the fever. 
It is very clearly proven that the typhoid fever, or dothinenteritis, 
is not contagious. Dr. Louis informed me that, in the course of his 
long experience of the disease, he had never seen a single case origi- 
nating in an hospital. I have seen but one. The contrast between 
the fevers, in this respect, is obvious. 

Age of the Patients. — After childhood, the age seemed to exercise 
but little influence upon the susceptibility to the disease. But chil- 
dren were rarely attacked by it. None of the children in the Asylum 
attached to the hospital, where there were about two hundred, were 
taken ill. Nor in the inspection which I made as a member of the 
Board of Health, of the houses in the infected district, did I discover 
many children who seemed to be labouring under the fever. After' 
childhood, the age of patients seemed nearly without influence. Thus, 
of sixty-six whites, there were thirty-five below the age of 35 years, 
and thirty-one beyond that age, and, on adding the number of nurses 



* Two other eases of assistant nurses also originated from similar coDtact, but 
as they were persons of less intelligence, I have refrained from relating their cases, 
u they offer less ondoabted testimony. 



158 Scientific Intelligence. 

and patients taken ill in the wards, we shall increase the number of 
persons older than 35 years, or passed the middle of life. The blacks 
give a greater proportion of young persons, although there were patients 
amongst them who were far advanced in years. But their compara- 
tive youth is easily to be accounted for by the large number of blacks 
engaged as labourers and inhabiting the infected part of the town, 
very few of them are old or middle aged men. Another reason is 
the habit of the blacks to state themselves younger than they really 
are, partly from ignorance of the value of numbers and of the precise 
year of their birth. It would, therefore, g^ve incorrect results to in- 
clude them in our estimate. The age of these patients differs much 
from that of those affected with the typhoid fever, or dothinenteritis, 
who are all younger, the disease almost never occuring above the 
age of 35 years ; the average for Paris and Philadelphia is 22^ and 22 
years. (See Louis on Typhoid Fever, and American Journal, 1835.) 

The sex seems to exert little influence on the liability to the dis- 
ease. The numbers were 120 men and 94 women, which is about the 
relative proportion of our ordinary patients. This result differs but 
little from that observed in typhoid fever, where, asleris paribus^ 
men are perhaps a little more subject to it than women. 

The change of life and habits from country to town was of no im- 
portance, our patients were nearly all resident for some years at 
Philadelphia, and some had been paupers for many years; their food 
and mode of living remaining unchanged during that period. The 
disease was not, as dothinenteritis, nearly confined to those persons 
w*ho had recently removed from one place to another. 

Use of .Ardent Spirits, — ^The most perfect temperance did not prove 
a safeguard when exposed to the contagion, as was shown by the 
cases of two of the resident physicians and of many others. Still, as 
a large majority of our patients were known to be intemperate, it 
would at first sight appear that intemperance was a powerful predis- 
posing cause. But the habits of the day-labourers are such that but 
few of them abstain from using spirits more or less freely, so that the 
number of typhous patients who were intemperate does not greatly 
differ from that of those affected with other acute diseases. IVlost of 
the women were not given to intoxication. 

Season of the Year, — ^The epidemic began in March, and continued 
until August. There were a few scattering cases afterwards. The 
summer was unusually cool, and the spring and winter cold. It 
was remarked, that as the summer advanced, and an epidemic dys- 
entery appeared, the fever was changed in character, and frequently 
offered a new symptom, that is diarrhoea, which was wanting in the 
earlier months. 

Occupation^ Sfc. — Our tables do not give us all the necessary in- 
formation on this subject^ nor would it be quite correct to receive 
their statements. The number of patients admitted with acute 
disease from the better classes of mechanics was extremely small, 
unless the subjects of it had been reduced to poverty by previous 
intemperance. Most of the blacks, like others of their race, were 



Scientific IfUelligence. 159 

emplojed aa mere day-labourers, chiefly masona' laboarers, and steve- 
dores. The poorest classes, whatever might be their occopatioa, were 
evidently more exposed to the disease than those uho were ncher, 
chiefly, perhaps, from their crowded and ill-ventilated rooms, as few 
of them had actually suffered from want of a sufficient supply of food. 

Colour, — ^The proportion of deaths amongst the black men was 
much greater than amongst the whites, thus of the whites, one died 
in 4} ; amongst the blacks, one in 2^. Amongst the women the 
reverse was true; thus, one white woman died of 4j-; but only one 
coloured woman in 6| nearly. These two results would, therefore, 
appear contradictory, unless explained by other causes. 

Age. — Twenty- two patients, eleven male and eleven female, both 
white and coloured, were admitted under the age of twenty, (from 
ten to twenty years,) of these not one died. Youth, then, was almost 
a safeguard against the danger of the fever, and this charmed age 
(from ten to twenty) was as free from the danger of petechial fever, 
as from most other causes of death. From the age of twenty to 
thirty, of women there died one in 5|, and in men nearly one in 4« 
It should be recollected that the largest proportion of deaths amongst 
the men of the age above-mentioned, occurred in blacks, who noto- 
riously underrate their ages, especially the men who were employed 
in occupations and under circumstances which rendered it difficult 
for them to fix their dates as accurately as the women, many of whom 
were domestic servants. Amongst the whites the mortality of the 
men between the ages of twenty and thirty was only a twelfth, but 
amongst the women it was as high as a fourth. Therefore, after making 
allowance for the causes of errors alluded to we shall have but a 
small difference in favour of women under the age of thirty. The 
deaths amongst the women above the age of thirty were one in five 
nearly. The influence of treatment upon the mortality will be after*, 
wards noticed. 

Pathological Anatomy, — Dr. Pennock and myself examined a very 
large number of the bodies of those patients who died of the fever. 
Indeed, during nearly the whole epidemic scarcely a single examina- 
tion was omitted, excepting in cases where it was impracticable 
from the removal of the body by the friends, immediately after 
death, or where putrefaction supervened, as it sometimes did almost 
immediately after dissolution. Jn this large number of autopsies, 
amounting to about fifty ^ there was but in one case^ and that 
doubtful in its diagnosis, the slightest deviation from the natural ap- 
pearance of the glands of Peyer, In the case alluded to, in which 
there had been some diarrhoea, the agglomerated glands of the small 
intestine were reddened and a little thickened; but there was no 
ulceration and no thickening or deposit of yellow puriform matter in 
the submucous tissue. The dbease of the glands resembled that 
sometimes met with in smallpox, scarlet fever, or measles, rather 
than the specific lesion of dothinenteritis. In all other cases, the 
glands of Peyer were remarkably healthy in this disease, as was the 
surrounding mucous membrane, which was much more free from vas- 



160 Scientific Intelligence. 

cular injectioD than it is in cases of various disease not originally 
afifecting; the small intestine. 

The mesenteric glands were always found of the normal size, 
varying, as in health, from the size of a small grain of maize to three 
or four times these dimensions. With the exception of a slightly livid 
lint, common to them and the rest of the tissues, they offered nothing 
peculiar either in consistence or colour. 

Tiie spleeft was of the normal aspect, in one half the cases, in the 
other half it was softened but not enlarged, and in one case out of five 
or six, enlarged and softened. 

Thus, the triple lesion of the glands of Payer, mesenteric glands, 
and spleen, constituting the anatomical characteristic of the dothin- 
enteritis or typhoid fever, although sought for with the greatest care, 
evidently did not exist in the epidemic typhus. Indeed, it was a sub- 
ject of remark, that in the] typhous fever, the intestines were more free 
from lesion than in any other disease accompanied by a febrile move- 
ment. This exemption extended to the large intestine until the sum- 
mer heats began, when a few scattering oases o£Pered some symptoms 
of diarrhoea, during the prevalence of an epidemic dysentery ; and, 
where they terminated fatally, softening, and other signs of inflam- 
mation of the mucous coat of the colon were observed. 

The fact that the morbid changes pathognomonic of dothinente- 
ritis, are not met with in the typhous fever, would of itself seem con- 
clusive that the two diseases are no more identical than pneumonia 
and pleurisy. Although, in some respects, the two affections are 
analogous, and even similar, the radical difference of anatomical 
lesions is at least as well marked as the distinction between the syrop> 
toms. It is, indeed, singular that there should of late be a strong 
tendency to confound two fevers, which were regarded as entirely dis- 
tinct by some of the older physicians. The prominent symptoms and 
difference of treatment being particularly well pointed out by Huxham. 

I have prepared for publication a case of dothinenteritis, and one 
of malignant remittent, or as it is called in southern states, congestive 
fever. These cases occurred during the past summer, when the epi- 
demic of typhus still continued. The appearances observed on dissec- 
tion did not differ from those already described in this Journal, in the 
report of cases which I published in the year 1834. In the dothinen«> 
teritis there were inflammation, and ulceration of the glands of Peyei', 
with a diseased condition of the mesenteric glands, and of the spleen. 
In the case of remittent fever, the lesions were limited to softening 
and enlargement of the spleen and liver, and inflammation of the 
mucous coat of the stomach. 

As their publication would extend the length of this memoir be- 
yond the limits of a Journal, I refer the reader to the cases reported 
in 1834. The fevers differed in their symptoms, as well as in their 
anatomical lesions. TliO symptoms of these different affections will bo 
compared in the concluding part of this memoir, at present, and I shall 
consider the anatomical lesions only, which were as different in each 



Scientyic Intelligence. 161 

ibrm of fever aa the puatales of smallpox are unlike the emptioa of 
measles. The anatomical characters of these varieties of fevers are 
peculiar to themselves, and it is as impossible to substitute the lesion 
of the follicles of the small intestine observed in the typhoid fever for 
the pathok^ical phenomena of typhus, as it is by treatment or other 
means to transform the eruption of measles into the pustules of small- 
pox. 

We shall hereafter inquire if the symptoms are equally distinct and 
characteristic in these fevers, which, from an abuse of names, are so 
often confounded with each other.— i^mertcan «/ot<rn«/ of the Medi^ 
cal Sciences f Feb. 1837. 

Peculiarities in the Feet of the Javanese and Dyaks.-^The 
Javanese seamen surpass Europeans, in agility in climbing the rig- 
ging, and indeed in this point are only inferior to monkeys. One of 
the principal causes of the superiority of the Javanese to the Europe* 
ans in working aloft, consists in the use which they make of their 
toes. In climbing a rope, instead of swarming up, the rope is 
grasped both by the hands and between the two Brst toes of the foot, 
and is ascended hand over hand like a ladder. On one occasion I saw 
a whole ship's company thus ascend the rigging to reef topsails ; the 
the ratlines (the small ropes which are fixed across the shrouds like 
the steps of a ladder) had been taken down ; hut this circumstance 
created no difficulty, and they all got up nearly as quickly as if the 
ratlines had been there. A seaman when splicing a rope, or sewing 
ii piece of canvass, hc^ds the article between his toes ; and a carpen-^ 
ter steadies, in like manner, a piece of wood that he is shaping and 
therefore retains both hands at liberty to handle his tools. — The 
Eastern Seas, by Mr. Earl, 1837. 

" The Dyaks (aborigines of Borneo) are of the middle size, and 
well formed. ^ • * Their feet are short and broad, and their 
toes turn a little inwards, so that in walking they do not require a 
very wide path. The native paths are consequently found very in- 
convenient by an European traveller; on my visit to the gold mines 
I obtained practical experience of this fact ; the paths used by the 
Dyidu and Chinese being generally worn down several inches below 
the surface of the soil, and as they are very little wider than the foot, 
pedestrian exercise proved both painful and fatiguing. The Chinese 
guides told me that I should soon become accustomed to these by- 
ways, from which I judged that the settlers had adopted the native 
mode of walking, with one foot before the other, since their arrival 
m the country, and I was the more inclined to this supposition, from 
the circumstance of the two interpreters having soon knocked up; 
one of them a native of China, a stout paunchy man, must have been 
particularly distressed, since he was in the habit of viralking with his 
toes much pointed outwards. — Ibid, 

Oriental Craniology, — " The Dyaks (inhabitants of Borneo) 
''are Pagans, and have many singular articles of belief, but that 

" VOL. XII. NO. 34. Y 



162 Scientific Intelligence. 

'* portion of their creed which obtains the greatest influence over 
*' their mode of life, arises from a supposition which they entertain 
" that the owner of every human head which they can procure will 
«< senre them in* the other world. The system of human sacri6ce is, 
** upon this account, carried to so great an extent, that it totally 
f* surpasses that which is practised by the Battas of Sumatra, or, I 
** believe, by any people yet known. A man cannot marry until he 
** has procured a human head, and he who is in possession of several 
** may be distinguished by his proud and lofty bearing, for the greater 
«< number ef heads which a man has obtained, the greater will be 
*^ his rank in the next world ; and this opinion naturally induces his 
** associates to consider him entitled to superior respect upon earth.*' 
The necessity of obtaining a human head to grace the marriage rites, 
forms a check to the increase of population never before thought of. 
This superstition accounts for the perfection to which the art of pre- 
serving human heads is carried in many of the islands of the Eastern 
Archipelago, New Zealand for example ; and it likewise explains why 
travellers are so frequently decapitated in those countries. The chieft 
sometimes make excursions of many hundred miles for the purposes 
of surpising and slaughtering the inhabitants of remote villages, in 
order that ihey themselves may be assured of having a numerous body 
guard in the next world. The heads thus obtained are dried and 
brought home by their captors, and are then stuck up in the most con- 
spicuous places about their houses. — Ibid. 

Snake Charmers. — A man of this profession in Egypt, named 
Mustapha, was frequently seen to take up the most poisonous snakes . 
by the tail or any part of the body without receiving any injury, 
though they were neither deprived of their poison- bag nor of their 
fangs; and the reptile, when moving to seize his hand, was observed 
to withdraw his head as if wanting <;ou rage to bite it; but the same 
man was careful not to allow it to approach his face or legs. And 
this precaution being confined to those parts, suggested the probabi- 
lity of his bands being smeared with some substance whose smell was 
intolerable to the snake, and thus served as a protection from his 
bite. — Lane* 8 Manners and Customs uf the Modem Egyptians. 

Egyptian Dancing Madness^ and Fire-eating. — Professor 
Hecker has written a valuable and elaborate history of the dancinjp 
madness that seized multitudes of religious fanatics in the middle ages, 
and of which the name is still preserved in our nosology, under the 
title of St. Vitus* s dance. The eiOfects of various positions and motions 
of the limbs and body on the mind have not yet been studied by phy- 
siologists with all the attention the subject deserves and requires. 
That attitudes and postures exert a very important infloence on the 
mind may be proved by the effects of the manipulations used by the 
practisers of animal magnetism, and by the testimony of actors, who 
acknowledge that it is diflicult to assume the posture indicating any 
passion, without feeling more or less of that particular emotion. We 
cannot throw ourselves into the attitude of the striking combatant 



Scienti/ic Intelligence. Ift3 

without feeling sometvhat of the ardonr which woald give strength to 
his blow ; neither can we imitate the shrinking posture of the terrified, 
or the headlong flight of the parsued, without partaking more or less 
of their fears. To a certain extent this circumstance, combined with 
4he contagious nature of fear, may explain the difficulty of rallying 
troops once they have turned their badcs to the enemy ; and even th^ 
bravest and best disciplined soldiers^ in retreating leisurely before an 
advancing foe, find it a task to proceed in good order. The attitude3 
of the female dancers at Gades, described by Martial and Juvenal, and 
those of the Egyptian public singing girls called Ghawazee^ exert an 
influence over the passions not only of the spectators but of themselves. 
Some dances consist of motions calculated to excite an amorous, some 
a martial spirit. The latter are the chief favourites of barbarous, the 
former of more polished nations ; and without fear of giving offence, 
we may be permitted to rank the waltz among the physiologically 
erotic species of dancing, although we do not quite agree with Byroa 
in unconditionally reprobating its introduction amongst the English^ 
Again, among the ancients, the value of forms in encouraging feel- 
ings qf devotion or respect, seems to have been fully understood, and 
certain postures were accordingly scrupulously enforced in the ce- 
remonies of religious worship, or in the respects paid to kings and 
princes. Hence the different values attached in different parts of the 
world to prostrations and g^uflexions, when a subject approaches his 
sovereign; matters which the unthinking regard as mere idle cere- 
monies, but which the physiologist must consider as founded on the 
lact, that these positions do actually increase the awe felt on such oc- 
casions. The priests and priestesses roost celebrated among the an- 
cients, never thought themselves inspired, never ventured to utter 
oracka, even at Delpbi, until they had worked themselves into a 
frenzy by a qoick succession of forced attitudes and grimaces. In 
Orand Cairo, at the public festival of the Mohhaaram, and others kept 
periodically, the whole population of Cairo, says Mr. Lane, is on the 
move, when the crowding, jostling, and pushing in the narrow streets 
and in the mosques is quite intolerable^ ** At these times the convolving 
** and dancimg dervises are performing their tricks over every part of 
** the town, blasphemously bawling out the name of God, and asking 
** charity in the terms of the Koran." Mr. Lane says, '* that each 
*^ seemed to be performing the antics of a madman ; now moving his 
** body up and down ; the next moment turning round ; then using odd 
<* gesticulations with his arms ; next jumping, and sometimes scream- 
** ing ; in short, if a stranger observing them, were not told that they 
** were performing a religious exercise, supposed to be the involun- 
'' tary eflfect of enthusiastic excitement, he would certainly think that 
'* these dancing dervises were merely striving to excel each other in 
** playing the buffoon.*' We cannot agree with Mr. Lane in this opi- 
nion, and have no doubt that the motions of the frantic dervises, pro- 
perly analyzed, would be found essentially different from those of a 
buffoon. 

Thus, says the writer of an article in the Qtiarterly Review, 
they dance and whirl till they become as crazy as our own 



164 Skientific inteUigenee. 

Irvingites, with their gibberish, bowlings in an unknown tongue ; 
but the feat perfonned by one of tbese enthusiasts, is so surprising, 
that we must transcribe it : '; In the middle of tbis ring was placed 

a small cha6ng dish of tinned copper, full of red hot charcoal ; 
" from this the dervise just spoken of, seized a piece of live charcoa^ 
" which he put in his mouth ; then did the same with another and 
'* another, until his mouth was full ; when he deliberately chewed 
^* these live coals, opening his mouth wide every moment to shew 
** its contents, whico aAer a few minutes he swallowed ; and all this 

he did without evincing the slightest pain, appearing during the 
^* operation and after it to be even more lively than ever. The other 
** dervise, before alluded to as half naked, displayed a remarkably 
** fine and vigorous form, and seemed to be in the prime of his 
" age. AAer having danced not much longer than the former, his 
** actions became so violent that one of his brethren held him ; but 
** he released himself from his grasp, and rushing towards the 
'* chafing dish, took out one of tbe largest live coals, and put it 
** into his mouth ; he kept his mouth open for about two minutes, 
** and during this period, each time lie inhaled, the large coal 
'■ appeared to be of almost a white heat ; and when he exhaledi 
** numerous sparks were blown out of his mouth ; after this he 
" chewed and swallowed the coal, and then resumed his dancing.'' — 
Ihid. 



i€ 



€i 



«< 



«C 



A Charm put to the Test — A circumstance occurred to this 
poor woman, which is strongly characteristic of the blind super* 
stition of the natives in tbis part of Africa. She imagined that 
she possessed a charm which rendered her invulnerable to all edge 
tools and cutting instruments ; so positive and so convinced was 
she of the efficacy of her charm, that she voluntarily assented to 
bold her leg whilst some person should strike it with an axe. 
The king on hearing this determined to try the power of her 
charm, and desired a man to take an axe and see wliether this 
wonderful ma§Kany would protect her from its efiects, considering 
that if it did so» such a charm would be of great advantage in war* 
Her leg was laid on a block, and a powerful blow given bdow the 
knee, when to the poor woman's great horror, and tbe terror of all 
present, her leg flew to the other side of the room. She sorvived 
\U and now crawled about on her knees* — Narrative of an Exp^ 
ditian into the Interior of Africa^ by Laird and Oldfield. 

m4/rican Cosmetici.-^The Felatab Ladies are very particular in 
adorning and ornamenting their persons. Their toOet occupies 
them several hours, and preparations are commenced the night 
before by laying the leaves of henna, moistened, to their toe, finger-* 
nails, and hands. On the following morning the leaves are re- 
moved, the parts being stained of a beautiful purple colour. They 
have mi extraordinary practice of staining the teeth with the acid 
of the goera nut and indigo, by which a blue colour is produced ; a 
yellow dye is produced by mixing the goora nut with a small 



Scientific InteUigence. 165 

8hrob ; the four front teeth of the upper and under jaw are dved, 
one of a blue, the next of its natural colour, the next purple, and the 
next yellow ! The eyelids then are pencilled with tba> sulphuret 
of antimony, and the hair, plaited in perpendicular knots four or 
five inches long, is bedaubeci all over with moistenened indigo, so 
as to resemble a blue helmet in appearance. — Ibid. 

Guinea Warm*^DracuncuIu$ is a very frequent disease iti 
Western Africa, and every trifling degree of inflanunatton of the 
skin, such as a boil, is considered by the Negroes as Guinea 
worm. An instance occurred in the person of the Krooman 
named Straw Hat. He had had a boil on the upper part of the 
foot, and supposing it to be a guinea worm, he applied some 
escbarotic herbs to it, which still more inflamed the part, and pro« 
duced excessive sloughing of the tendons. On the ligaments of 
the toe becoming exposed, the man passed a piece of strong black 
thread round two of them, (supposing the other to be a worm 
coiled up,) near the instep, and then secured a piece of lead on the 
outside, for the purpose, as he said, of dragging away the worm. 
This morning I insisted on seeing it, and found that several inches 
of tendon had actually come away. In order to convince him of 
his error, I procured a fowFs foot, and by pulling the back tendon 
brought the other into action ; I then dissected the front part of the 
foot, and exposed all the ligaments. 

After this explanation SUraw Hat seemed quite satisfied. I 
might have talked a twelvemonth to him to no purpose, and if I 
had not had recourse to ocular demonstration, I should never hav6 
succeeded in convincing him of his error.— 76u^ 

Surgeon Oldfield, cme of the authors of the work from which we 
have made the preceding extracts, was of great service to the 
expedition by means of the reputation his skill had acquired 
among tlie natives ; one of his most interesting remarks on their 
prevailing diseases is, that cataract is extremdy common, and 
deprives multitudes of sight. In Egypt and Northern Africa loss 
of vision is generally caused by inflammation, commencing in .the 
conjunctiva ; but we believe that cataract is not there prevsJent in 
more than the usual degree. If this fact be confirmed by succeed- 
ing observers, an interesting question will arise as to the causes 
which render cataract so much more frequent among the inhabit- 
ants of the banks of the Niger, than among those of the banks of 
the Nile. Will the difference of race account for the fact P 

Obesity in Africa. — It was a subject of remark among us, and 
occasioned some amusement, to see the diflerent efifects o? heat on 
different constitutions. Sometimes with the thermometer at 84, I 
felt cold in a blanket dress, and at other times at 75 I was 
oj^ressed with heat; it appeared, however, to depend much on the 
moist or dry state of the atmosphere. I found that a very simple 
rule had hitherto kept me in excellent health; if I felt sleepy after 
a meal| I considered it a gentle hint from my stomach that I wk 



166 Scienti/ic IfUelligence. 

• • - 

over- working it, and reduced my fare accordingly. In fact, I tbonght 
the less one consumed the better, as all our party appeared to have 
a most unaccountable propensity to become jat, I did not eat ohe- 
half that I had been accustomed to do in England, and yet could not 
keep myself from increasing. Dr. Briggs was precisely in the same 
way ; and as for Lander, he was as broad as he was long 1 — Narrative 
of an Expedition into the Interior of Africa, 

Singular Origin of Fever. — At day-light on the 22nd, we com- 
menced breaking out the main hold, preparatory to lightening the ves- 
sel of all superfluous stores, before proceeding up the river. We had 
been frequently annoyed during our passage out by a disagreeable 
vapour that came from the hold, and we now found that it bad been 
occasioned by the cocoa being stowed in bags in the provision-room 
under the cabin. The bags had rotted ; this, I am of opinion was the 
principal cause of the unhealthiness of the after part of the vessel ; 
the two fatal cases of fever having occured in the poop, and no severe 
cases in the forecastle where the men are much more crowded to- 
gether. — Ibid. 

Superior Healthfulness of Iron Ships. — Tlie Iron Steam Vessel 
the Alburkahf was much healthier than the larger Steamer the 
Quorra. It was predicted in England, that the heat of a tropical 
sun would bake alive her unhappy crew as if they were in an oven; 
but the result was very different. Being in herself a good conductor 
of caloric, she was always at the temperature of the water in which 
floated. — Ibid. 

African Ague. — My mornings were generally passed in reading, 
but in the afternoons I was generally disabled by an attack of ague. 
The paroxysm generally came on at noon, and each successive one 
was invariably half an hour later until it arrived at six o'clock, when 
it would leave me for two or three days, and then return to begin 
again at noon. This order was repeated so often in my case that I 
coold tell to a minute when it was coming. — Ibid. 

African Poisoning Scene. — ^The £o\\ovir'mg poisoning scene presents 
some remarkable points of resemblance to similar scenes enacted by 
the enlightened Athenians, and the effects of the drug and of exercise 
and water in accelerating its action will strongly remind the reader 
of the death of Socrates — an interesting fact when we recollect that 
history points to Africa, as the source of Grecian civilization. The 
composure of the two sufferers seems likewise to have rivalled that 
of the celebrated sage of antiquity, although based on less philo- 
sophical grounds ; this too may form a subject worthy of deep re- 
flection. 

** I was witness to-day of a poisoniug scene, which it would appear 
** is a favourite punishment at Fundah. The culprits were two 
" women, who were placed under a tree in the court yard, and an 
<< old man beat up the leaves of some herbs in a sort of mortar, the 



Scientific Intelligence, 167 

^' wottMii sitting quietlj looking on. The liquid whith was of a 
*' greenish coloor, was poared into two calabashes, and the women 
*' drank it off without any apparent reluctance. They then coni- 
** menced walking up and down the court, drinking large quantities 
'' of water from a calabash placed in the centre of it. In about half 
^' an hour they both begaa to stagger and totter in their walk ; and 
'Mn a few minutes more the tragedy was ended by their falling flat 
" on the ground and expiring apparently in dreadful agonies."— /6uf. 

We must conclude these extracts from a Narrative of a Journey 
into Africa with a pathological dictum of King Obie, which ought 
to be prefixed to the next edition of the works of Abemethy and 
Broossais ; his sable majesty's pan^horism is *' When belly sick^ 
had palaver ^ very bad palaver I 

Misunderstandings produced by Patients. — Snch is the narra- 
tive. Now the lesson we would wish to draw from it consists in im- 
pressing upon our readers the caution — the extreme caution — with 
which they ought alike to make and to receife communications re- 
garding the previous treatment of patients. The confidence of the 
medical attendant is constantly violated, and no practitioner is safe 
who, in his interconrse with those who consult him, does not keep 
constantly in mind that what he says will be repeated by the patient, 
whenever it suits his purpose to do so, and probably with mistake or 
exaggeration. We appeal to every man who has been but a few years 
in practice, whether this is not the case — whether, as a general 
rule, the public shew any good faith towards their professional attmid. 
ants — any consideration whatever for the mutual feelings or points 
of etiquette which may be supposed to exist among medical men ? 
Whether, in short, there is any safeguard against the most confi- 
dential observations being repeated, excepting only where it is the 
personal interest of the patient himself to keep them secret? 

We have no reference to the mere facts of the preceding case in 
these remarks as to who was right and who was wrong, but we allude 
exclusively to the question as a general one. The correspondence 
referred to has very strongly forced upon our attention the difficulty 
under which the want of candour and the gossiping propensities of 
their patients often place medical men ; and we, therefore, seise the 
opportunity of directing their attention to the circumstance. No- 
thing is more common than to be consulted by a party who gives his 
own colouring to his previous state and previous symptoms — tells us 
a certain portion of his history and no more-- suppresses one part and 
colours another— probably draws from us an opinion which does 
not altogether tally with one he has formerly got from some other 
attendant, and having done thb he represents, in his own way, the 
nature and extent of the difference, as well as the language in which 
it has been expressed—and behold '* a very pretty quarrel" is the 
consequence. 

That there are jealousies and rivalships in our profession, as in 
others, all the world knows ; the odium medicum, we fear, is no ima- 



108 Sdentijllc IntriligeMce. 

gloary passioD ; but of thk we are quite eiire» that a great portion of 
the resulting evil maybe traced to the mistakea or iniarepreeeiilatioiis 
of the mutaa! patient, ^af , in the particular instance before u«, and 
on Mr. Boflhe'e own shewing, we percetre strong eyidence of ^iis« A 
ladj, he tells us, had weaned her inftuit *' without using any tneam to 
prevefit the febrile action which fometimes iahe place /rom that 
cause,*' Under these circumstances— that is, at a time when she re- 
quired certaiB remedies which had not been administered, she applied 
to another medical man who at once prescribed them. Now we put 
aside altogether what was actually said on this occasion, and limit 
ourselves to this, that the simple fact of administering different resae- 
dies implies a difference of opinion ; and we know from experience, 
that patients are not backward in coming to this conclusion— nay, 
they frequently go a step further, and, as we have abeady eaid, in 
order to justify themselves for leaving an old attendant, attribute to 
the new one expressions much stronger than he has actually used, and 
yerj possibly add some to which he has used nothing in the least ana* 
logons. 

Ag^in, we shall suppcse that a patient obtains the opinion of a 
medical man as to his case, and that it really is essentially different 
from what has been given by another : can anything, we ask, be more 
unjustifiable than to proceed straightway to the house of the first ad* 
▼iser, and repeat certain expressions, which, if used at all, must havo 
been used in confidence ? If this is to be done, how can such patient 
expect ever again to obtain the free and candid opinion of any medi- 
cal man* 

Let it not be supposed that we would countenance or extenuate a 
piece of unprofessional conduct, come from what quarter it may ; bat 
in the present instance there is no evidence of any such having been 
committed, and our only motive for alluding to it is to avail ourselves 
of the opportunity of putting prominently forward, in connexion with 
a particular case, what we have long been convinced of— 4iam^, tbat 
half the differences among medical men, with regard to points of eti- 
quette occurring in practice, depend upon the disingennonsness of pa- 
tienti who, when they wish to change their attendant, do not stick at 
a trifle to excuse themselves to him, and wiH rather attribute the ctr- 
cuntttance to something else than the simple motive of their love of 
change, or less of coafiidence. He who listens to the tale should at 
least keep in mind that a statement, the making of which involves, 
ipso facto, a breach of confidence, ought always to be received with 
dis trust. 

The longer we live the more we are convinced tliat medical men 
generally give their patients credit for more discretion and geod fkith 
than practically they will find them to display ; at all events, so much 
of what they say is misunderstood, or misapplied, that they c«inot be 
too careful in avoiding any expression which can by possibility be con- 
verted into censure of the medical man who has preceded them ; 
for when the patient has changed his '* Doctor," he jumps with his 
onn conceit to be told that he whom he has discharged was uade- 
serving of his confidence.— Medico/ Oazeite, Aug. 12, 1837. 



THE 



DUBLIN JOURNAL 



or 



MEDICAL SCIENCE, 

1 NOVEMBER, 1837. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. IX. — Observations on Fever. By Robert Law, M. D., 
Fellow of the College of Physicians In Ireland, Physician 
in Ordinary to Sir Patrick Dun's Hospital, &c. &c. 

Meehoins 18 often charged with being an uncertain, an unsteady, 
capricious art, and when flippant wit would indulge itself at its 
expense, it puts into the physician's mouth, on a changi tout 
eela. So far irom seeking to deny the charge, we admit it in 
its fullest extent, but lay it mainly at Nature's door, which, by 
▼arjring disease, has imposed upon medicine the necessity of 
aeeommodating itself to its diversified character. We must 
even assert, that medicine and medical science have been more 
retarded in dieir progress by attempts to impose upon them a 
ixedness and steadiness of character, of which they do not ad- 
mit, than by any other circumstance. When we reflect upon 
the principal sources of disease, we find them to be such as are 
in themselves changing, and variable, and therefore it is natural 
to expect that their efiects would exhibit the sane changing 
character. AoiODg these sources we would assign a prominent 

YOL. XIL NO. 35. z 



1 70 Dr. Law's Observatiom on Feter. 

place to the influences of the atmosphere in the midst of which 
we live, for although chemical analysis can discover no diffe- 
rence between tliemost salubrious and the most unhealthy atmo- 
spheres^ on the tfcoiv of their ^ndionaetrical prQpMties» still the 
striking differences which the diseases of one year exhibit^ when 
compared with those of the preceding and subseguent ones^ fur- 
nish incontestible eyidence^ that the atmospheric constitution 
cannot always be the same. If ever there wt&a time when at- 
mospheric influence forced itself upon our i^otice, as an active 
agent in producing and in modifying ^li^ase, it has been with- 
in the last few years. Within this period, not only have we 
been visited by diseases to which we bad hitherto been stran- 
gers, but every known and fawiliar disease has exhibited itself 
under an aspect of malignity quite new to it. Thus, in addition 
to cholera and influenza, (which, although not a completely novel 
disease, yet spread in such a way, and assumed such a degree 
of sev^erity, as were quite unusual with it,) erysipelas, .maligr 
hapt scarlatina, diffuse inflammation of the cellular memWtne, 
prevailed to an unprecedented extent. The cases of mpdified 
small-pox now, also, crowded upon us ; and it was now that 
fever began to prevai]« and we Tnay say, that for more Sum tM 
years Dublia \m been 4he aeat of an epidemic tjrpboid fevar* 
For although during nil this time the disease has not alwa^ ex^ 
isM to the same extent, upr has it oMMbtaiaad « wifbnnity of 
severity, stiU tb9 ^stv^es hove ever been mare nuDAi^us than om 
djnarily ; and lyhatever modificatioBs they oaay hAVttiilideiQo«(a^ 
th^' haw almy^. obaemned the 4iaraoteristio U$i%r^$^ A« pner. 
vailidg epidemic. » 

It k weU known that there ncnrer was « period bftbe IMorji 
of jnedicine, when tbe exaot padiologiQal aatwe of feiwr wail 
more aaul^ct of controversy tfaan«4 preamt ; net-did nvMoe di£i 
ieieace of ophuon ever prevail upon the aubjaott t 

The fif$t graod ^estion i$, wbetiiar fisver ibe eaaeolMdlyiemH 
nectad with, and dependent upon palpable msA oirgtmic leaian } 
or in other word% vrfaeOisr all fiMera ba |«H)pari]r/3yi 



I>r. Law's Observatiom M fe^er. 171 

or not. Th& next question is^ w to^ the seal or loealify oCfevMr : 
various have been the situations and organs that have fa)e«i se^ 
lected as its proper seat; and as various have been the deaomi- 
nations that have been affixed to ttie' disease. Thus has it been 
designated gastro-enteritis^ entero-mesenterilis> follie«lar-eiileci« 
tis, dothinenteritis, &c ftc 

Deeply interested in these questions, from a- fevling of tikttw 
great practical impoitancci we determined to- avail ourselvieff 
of tiie occasionf to trf and aseerlxiin the exact truth. We 
confess we were in no small dlsgree surprraed, at ijaB^eotameoc^ 
inent of the epidemic, to see in how many case^ ai^. to what 
an extent actual disofgaitkation; someliaiesamouiitMigto slough^ 
ing of the structure of the terminatSott ofthe^iiion^ and ^'the 
glands situated there, was found to exist. We tfiought withiii 
ourselves, could such lesions have existed in former fenera^ and 
from inattention have been overlooked ? It was haiid to conceive. 
Again, we remembered, that althoogh no where is fever more 
prevalent, and, perhaps, no where more fetal than in oar eify> 
and consequently no wher6 is there more opportmrity of investi- 
^ting its pathological nature ; so few werethepatbologica) spe- 
cimens of this ulcerated condition oFthesmall intestines and the 
mucous gliands in the museum of the CoHegeoKSurgeofis, that 
our valued friend Mi^. Houston, the Curator, set especial vriuo 
upon one with which we had an [opportunity of fomishing him a 
few years since, nor had this specimen any ottier pretension to 
his favour than its rarity, it being, we believe, the* onty one h/^ 
then had. Had the lesion been nearly as common as fever, 
whose victims principally supplied the dissecting rooms, we cao- 
liot suppose it possible that it could have escaped the close ob- 
servation of the intelligent pathologist, of whose talent and zeal 
the rich pathological collection in the museum of the CoHege 
of Surgeons is a proud monument. 

In the course of the last year, we had an opportunity of 
conversing with M. Andral on the subject. Although he did 
Aot seem altogether decided^ that the intestinal lesion was the 



172 Dr. Law's ObsenMitions on Fever. 

essential anatomical eonditioDj or the sine quA non of fever^ still 
it was quite obvious that the frequency of it had given a decided 
bias to his judgment We reminded him of our having followed 
his visit with M. Lerminier» at La Charit6> about twelve years 
before^ when we had observed many cases of typhoid petechial 
fever, and had witnessed not a few poH mortem examinations 
when this lesion was not noticed. He conceived it possible 
that it might have existed, but have been overlooked from at- 
tention not being particularly directed to it We found it very 
diflScult to acquiesce in the opinion, that so accurate an observer 
of pathological appearances, whose patient industry we had so 
often witnessed and admired, could overlook any thing even 
like the disorganization that later investigations brought under 
our notice in similar cases, and especially too, at a time when 
he must have been engaged in collecting the material for his 
valuable work on pathological anatomy. M. Louis answered 
us more decidedly, stating it as his unvarying experience, that, 
whenever in a case of fever he found the abdomen tympanitic, 
the surface marked with lenticular petechiae, and a sense of 
gurgUng or gargouillment when the ilio-coecal region of the ab- 
domen was pressed, then he was sure to discover, on examina- 
tion after death, an affection of the glands situated towards the 
termination of the ilion. We are found so far to consent to the 
opinion of M. Louis, that we have met with extremely few 
cases of ulceration of the intestine, in which there did not exist 
tympanitis, petechise, and ilio-coecal gargouillment; still we have 
met with all these symptoms in the most aggravated and the 
most rapidly fatal cases of typhous fever, when examination after 
death could detect no trace of intestinal lesion. M • Bouillaud, 
whose clinique is more crowded than that of perhaps any other 
physician in Paris, teaches that typhous fever is an entero-me« 
senteritis, and treats it with a degree of activity and energy, 
which we own we should not have felt ourselves warranted in 
pursuing ; nor have we reason to regret the results of a mode of 
practice diametrically oppointe to what an active inflammatory 



Dr. Lbw*8 ObBervatione on Fever: 1 73 

disease would demand. In many and the most aggravated cases 
of typhus^ the single and simple indication which presented it- 
self to us was to feed the expiring lamp of life ; and in not a 
few of such cases, wine has been the only remedy we have em- 
ployed from the time they have come under our care, till we 
have pronounced them convalescent. 

The epidemic which still exists, and which we before stated 
has existed for now more than two years, ^ brought under our 
notice almost every modification of fever, not only such as de- 
pended upon individual peculiarity or idiosyncracy, but under 
all the varied aspects impressed upon it by change of season* 
Thus in winter and spring, have we had it accompanied by 
bronchitis, and that not of the nature of that which alone indi« 
cates itself by sibilant rale, and which we should perhaps 
overlook, did we not apply the stethoscope to the chest, and 
which is so often to be met with in iever, that Laenneo regarded 
it as constant, but so extensive and so aggravated, as literally to 
produce sufifocation by the copiousness of tlie efiusion into the 
bronchial tubes, as well as into the parenchyma of the lungs. 
Some of these cases dosely resembled Armstrong's Congestive 
Fever, and on examination of the bodies after death, we gene- 
rally found the lungs both anteriorly and posterioriy in such a 
state of engoument or congestion as we ordinarily only find ki 
the posterior part, and which we designate cadaveric conges- 
tion. In such cases the congested org^n generally resembled 
the softened spleen, and admitted of being easily torn. Pheu- 
monia complicated some cases, and exhibited to us some ctihe 
most striking specimens of suppurative pneumonia, or in its 
third stage. The local affection generally came on very insi- 
diously, indicated often neither by cough nor by dyspnoea ; nor 
did it exhibit the same predilection for the inferior part of the 
lung, that ordinary pneumonia does : we as often detected it at 
first under the clavicle as elsewhere. These cases have tend- 
ed to confirm us in an opinion which we have ever entertained 
of poeumonia terminating in suppuration, that it deserved rather 



to be oon«d<9red as altfed tadSRise inflamnfttton of Die dEfitiar 
membrane^ than tb true genuine pneumonia. The constitcN 
tional ayniploBi» and toeal a])peMmnoe» or patbologmal' cbarae^ 
tistn 9eem to me bodi to warrant ihm opinion. The acoom]ph- 
Yiying FeVer is generatty of the typhoid type, and the anatomic 
characters are the same as wo find in Ai^ specie of inflamma- 
iton, vYB. eftisibn of lympfr into*t!he celltilar tinueof^e organ, 
imd* pundent infikration-into tJhe snbstonoe oftbis effused lymph; 
At the 'same tfme that we met with thia complicatfen- of Ifever 
and suppuratrre paemnohiay. we- also- met wittt easea^ of pfafegw 
itionoM erysipeha, and' nfeai^ a%rat Ate MAe time-a remarhas 
Ueoase cf laryngitis presents itself t» us; Ahnost aU the 
gympfoms cff fever had' subsided, we had in fact pronounced 
ovT' patient convalescent, when, at our mormng visit, we fbund 
tier in the greatest distress fitnn difflonlt respiration. She had 
been seized wift sore-tfiroat daring the night; The inspiratbns 
Wei5e'lbrtgi hoarse, andcronpy;' there was tendbmess on pres- 
ft^ ^tevfe the Ayn)id cartilage. Inspection of the feucea dTii^ 
ooverednotWng unusaal^, btrt the eprglbttis tovM be felt hard 
(md AMened; pulse 160, not strong,* we had herfitrgely leech- 
^ tetheth^^oat ; UKrtered t&O' nape of tiie neck, and directed 
ealbmeF wBfii a view to affect the naouth and as soon as possible. 
We strtmtousty persevered in tfitese- nreans^ and' her distress 
seesied consKferabiy lenened, stilt the pulse never was kwer 
ttan ISO'in the nrioute^ nor could' the systenr be breugfat under 
tfle* influence of mercury, although, in addition to the catouiel, 
^fe had the BUstered surface* dressed witir mercuriat ointment: 
At die end of five dSiys* she exph^d. Hie inlegumentls of the 
Aroai were very much swcrilen, and the partsr hardened and 
matted together; this, however, seemed' to be the effect of the 
feecbes and* bfisters that bad been applied in this situation. 
The ep^lotlrs was very much thickened and indbfated. tte 
sitifer of the rftna glottidis were so approximated, that it re- 
semUed ar cfeft made with a knife. Alf tfie parts were very much 
flHckeuedi and requnred a degree of ftrce to cut into tfont. 
When an incision was made into the thickened parts, there was 



Dr. Law's Observations on Fever. 175 

a thin purulent matter in the midst of the substance which 
caused the increased bulk of the parts. This substance was 
lymph^ eflfused into the submucous reticular cellukr tissue. It 
occupied the tissue which is more ordinarily the seat of oedema. 
The disease was strictly confined to the larynx ; there was no 
trace of its extension to the trachea, llie left lung exhibited 
a considerable extent of engoument, closely approximating to 
red hepatization. The subject of this case was a woman of na- 
turally vigorous constitution^ aged twenty-six^ and as far as we 
could ascertain^ was not exposed to any thing likely to produce 
the untoward complication. The point to which we attach es- 
pecial interest in this case^ is the lesion which we believe has 
not been noticed. The unequivocally inflammatory nature of it 
distinguishes it from the serous effusion into the same submu- 
cous tissue, constituting oedema of the glottis, and to relieve 
which, antiphlogistic means are so often unsuccessfully resorted 
to. It obviously differs, also, from the inflammation consisting 
in the effusion of lymph on the free surface of the mucous mem- 
brane, or croup : nor does it owe its rareness so much to the 
lymph effused into the sub^mucous tissue, as to the purulent in- 
filtration into this lymph, which is the pathological character 
which suggested to us its identity with diffuse inflammation. 
The incidental mention of this case has brought to our mind 
other cases of laryngitis, which we met with in the course of the 
epidemic, not, however, exactly like this one, yet not altogether 
different, ^^ fades non omnibus una, haud diversa tamenr In 
one of them, there was a large collection of purulent matter form- 
ing a tumour in front of the throat, opposite the pomum Adami. 
The matter diffused itself into the cellular membrane connect- 
ing the muscles at each side of the neck, especialljr about the 
OS hyoides, and the root of the tongue. Large masses of lymph 
were thickly laid on all the mucous membrane of the larynx, 
almost completely obstructing the rima glottidis. This lymph 
could be easily detached from the surface on which it is depo- 
sited. The subject of this case was a man of sixty years of 



176 Dr. Law's Observaiions on Fever. 

age* Althmigh we hare many cases of laryngeal inflammation 
connected with fever, and coming on at a time and under cir- 
cumstances which did not lead us to expect it, yet the limits of 
an article of this nature will not allow us to do more than mf^rely 
to glance at a few of them. We would here allude to a case of 
erysipelas of the head and face, in a female aged sixty, of not 
very temperate habits. When the swelling of the face was sub- 
siding, and the eyes had become open, the throat became affect- 
ed. Both respiration and deglutition were laboured and painful* 
Extreme prostration and. collapse of the system took place, and 
death quickly followed, hit. Porter, in his judicious observa- 
tions on Laryngitis, has noticed the similitude between erysipe- 
las aflecting the mucous membrane of the larynx, and diflfuse 
inflammation. We would further observe, that we have re- 
marked the tendency of laryngitis oedematosa to occur in, and 
to be the fatal termination of cases of constitutional irritation. 
This has been observed in a case of glanders in the human sub- 
ject, the symptoms of which were, in odier respects, the same 
as the effects of a dissection wound, or of the introduction of 
any animal poison into the economy. It is worth while fo re- 
mark, that during Uie prevalence of epidemic typlwus fever, 
the fever accompanying the exanthemata, (which, periiaps, pre- 
vailed to a greater extent than we had ever before seen them 
w&hin ihe same period,) in many cases assumed the same typhoid 
type. This was especially the case with scariatinaand erysipe- 
las ; the former particularly exhibited itself under this charac- 
ter, and literally carried off* entire families ; the latter, too, often 
created great apprehensions for the safety of those affected by it, 
and most so when it affected the head. It often arose sponta- 
90ously, but more commonly was caused either by blistens or 
proceeded from bed sores, against which, in many cases, the most 
vigilant cautions could not provide. Not only have we seen 
these sores to proceed from a part being pressed by lying upon 
it for a very short time, but also have observed them to be pro- 
duced by tfie Jegs being crossed, the weight of the upper one 



Dr. Law's Observations on Fever. \n 

acting upon the part of the one upon which it lay. We hold in 
mind one caae^ in which not a part that pressed the bed^ even the 
sole of the foot which was applied to the foot-board of the bed^ 
escaped ulceration. Professor Graves remarks, that when a 
bed sore forms, both doctor and nurse' should be dismissed, in* 
timating that their prevention is, in all cases, within the reach 
of the attendant's care. We have met with some cases of their 
occurrence, in which we feel perfectly satisfied that no vigilance 
of ours or of the nurses could have prevented them. These 
were cases, the subjects of which were of a gross, leuco*phlegma- 
tic habit When, in sudi cases marked by constitutional* ine- 
lasticity and deficiency of vitality, the brain and nervous system 
become oppressed, this untoward circumstance occurs, and in 
an inconceivably short time. We have observed die same to 
take place in cases of apoplexy, and obviously from the same 
cause, viz. the nervous influence being withdrawn, by reason of 
the pressure on the brain. Not only is the lightest pressure^ 
and that even for a very short time, competent to produce slough 
and mortification of parts in some instances, but we shall find 
the same to occur in parts which have not been subjected to 
pressure. We had a remarkable instance of this in a female 
who was convalescent firom mild fever. At our morning visit, we 
unexpectedly found her in bed, complaining that she felt herself 
very unwell, that she had had a bad smell, which she could not get 
rid of. Her countenance wore an expression of deep distress 
and anxiety ; the features were drawn, the point of the nose 
was quite purple and cold ; she seemed shrunk within half her 
natural sise, and had very much the wretched appearance whieh 
we sometimes observe with a person in the cold stage of inter- 
mittent fever. There was a complete collapse of all the pow^ 
ers of life ; no stimulants could rouse her ; she sunk in a very 
short time. We have had occasion to observe the tips of the 
ears mortify independently of pressure, and have seen the con* 
seqpi^t- ulceration the poini du depart of erysipelas of the 
VOL. XII. NO. 35. 2 a 



178 Dr. Law's Observations on Fever. 

* 

head and face. This we found a very embarrassing case, as con- 
flicting indications seerfied to present themselves. Delirium 
generally accompanied the erysipelas, yet the condition of our 
patient being generally that of extreme prostration, controlled 
us in the use of any but a nicely modified plan of antiphlogis- 
tic treatment. This, in general, consisted in the exhibition of 
a small portion of tartar emetic in a stimulant menstruuni. We 
also gave wine at the same time, and in some cases rather 
freely, which, so far from aggravating the delirium, had a decid- 
edly contrary eflfect. 

In summer and autumn, the epidemic assumed more the 
character of gastro-enteritis. It completely swallowed up the 
English cholera and dysentery which usually visited us at this 
period of the year. It now exhibited those features of charac- 
ter which foreign pathologists are disposed to regard as essen-. 
tial ; and, indeed, so constant were those features at this period, 
that scarcely a case was met with in which they were not to be 
seen. Diarrhoea was a most frequent symptom, and it was now 
that we had most frequent occasion to observe that most un- 
toward symptom, intestinal haemorrhage. 

Towards the close of the year, the epidemic seemed to 
merge, for a time, into influenza ; they seemed, at least, to mo- 
dify each other, the latter assuming the typhoid type of the 
former. 

At flie comraencement of tfie present year, the epidemic 
again re-appeared, and so extensively, that the government felt 
themselves caUed upon to provide additional hospital accommo- 
dation to meet the emergency^ It also appeared under a cha- 
racter of malignity, which it had not exhibited before ; it ter- 
minated fatally within a shorter period than it had done before, 
the patient, in some cases, exhibiting something like fan apoplec- 
tic seizure. Now it was that we especially had occa^on to ob- 
serve those complications, i/i^ich bespoke the lowest slate of 
vital energy, viz., different modifications of difibse Inflamma- 



Dr. Law's Observations on Fever, 179 

tlon, sudi as parulent deposits in diSerent parts of t]ic body, 
suppuration of the joints, p[K)rtification of parts, purulent pneu- 
monia, &c. • Yet under these circumstances we completely 
lost sight of ulceration of the intestine, not an individual in- 
stance of which have we seen for several months, till within the 
last week, when we witnessed two, each of which exhibited per- 
fect specimens of the particular lesion of the small intestine and 
of the mesenteric glands. The3e cases are somewhat uncom- 
mon : in neither were there petechias ; in one only was there 
tympanitis. One had diarrhoea, which yielded to a few grains 
of Dover's powder. Both, certainly, were in a state of extreme 
prostration. The intellect in each was perfect, although in one it 
was dull and slow. One died on the sixteenth, the other on the 
twenty-third day of hi^ illness. Theextent of organic mischief was 
greatest in that which proved fatal on the sixteenth day. The 
morbid appearances were of precisely the same, character in 
both* The stomach and duodenum and jejunum were healthy. 
We had also got through a considerable portion of the ileum be- 
fore any unusual morbid appearance met our eye. We first saw 
small round bodies, not larger than grains of small shot, studding 
the mucous membrane, and of the same colour as the mem* 
brane. Then were to be seen small circular ulcerations, with 
elevated margins, somewhat resembling variolous pustules. As 
we approached nearer to the termination of the intestine, the 
ulcerations were larger, situated nearer to each other ; afiecting 
various forms, Bome circular, others more of the form of an 
ellipse, with their longer diameter transversely, and exhibiting 
at their bottom the denuded muscular fibres. At the terminar 
tion of the intestines, were large sloughy patches, of considera- 
ble dimensbns, and with jagged shreds of cellular membrane, 
coloured with bilious excrementitious matters. These sloughy 
uloerations existed on the ilio-coecal valve, but did not. extend 
into the ccecum, nor was there any thing unusual, with the ex- 
ception of a little increased vascularity of the mucous membrane 
of tke large intestine. The mesenteric glands in each case 



180 Dr. Law's Observations on Fever. 

were enormously enlarged^ and when cut into exhibitisd a strik- 
ing resemblance in their substance to that of the kidney, when 
unusually vascular. The enlargement and vascularity of the 
glands plainly bore a direct proportion to the degree and in- 
tensity of the disease of the portion of the intestine nearest them. 
We observed the ulceration of the intestine always to occupy 
the convex portion of the intestine, or the remotest portion from 
the mesentery. Although we have constantly forty or fifty 
cases of fever under our care, these were the first instances we 
have had of this lesion for nearly a year ; a lesion which, before 
that period, was the most common morbid appearance in 
fever. 

From these cursory and general remarks on the epidemic 
fever, we shall notice a few of the most constant and striking 
features that characterised it. We feel no hesitation in setting 
down the presence ofpetechue as the phenomenon more rarely 
absent than any other. Hie most common period of their 
appearance was from the fifth to the eleventh day. Hitherto 
we had been in the habit of observing them in general only 
associated with a Cortege of symptoms so indicative of a bad 
and dangerous type of fever, that to pronounce a person in a 
spotted fever, was considered nearly tantamount to signing his 
death warrant But in this epidemic we met with this pheno- 
menon occurring in a fever so mild as scarcely to demand the 
interference of art 

The only cases in which petediite were not preset, were those 
of children. We do not remember to have seen a case of fever in 
achildunder twelve years of age in which they were to be seen, al- 
though in not a few instances have we observed purpura he- 
morrhagica. This modification apparently dependent upon age, 
occurred to us as more remarkable when we reflected how 
much more disposed childhood is to cutaneous afiections, that 
it is, in fact, the proper period of exanthemata. We conceive this 
circumstance is explained by the opposite condition of the ca- 
pillaries of the skin in the exanthemata, and in cases of peteGhi»> 



Dr. Law's Observations on Fei>€r. 181 

tfaey being in the former in a state of active erethism, while 
in the latter they would seem to be in a relaxed state. We 
bdieve them to be in the same condition of contrast, that they 
are in active and passive hemorrhage. The blood also in this 
particular kind of fever, seems to us to undergo a change con- 
sisting in a diminution of its density, which favours its passage 
into the relaxed vessels, and thus contributes to the formation 
of the petechiae. The older physidans regarded this dissolu- 
tion or breaking up of the blood as putreiaction, and to correct 
it, directed the medicines which they designated antiseptics; 
among which they assigned the foremost place to the acids. 
Although we deny that this altered consistency of the blood is 
putrefaction ot like it, yet we conceive it to be similar to the 
eflfect which some poisons are known to produce upon this fluid, 
dianging its consistency, and depriving it of its power to coa- 
gulate. We know that this fluid state of the blood is the only 
unusual appearance generally met with in the examination of 
bodies when death has been caused by lightning, and in other 
cases in which the nervous system has been the portion of the 
animal economy principally aflected. The petechias, so con- 
stant in the epidemic, presented various appearances. In some 
instances they so closely resembled measles, that had we the 
eruption alone to determine our judgment, we should not have 
found it an easy matter to decide between measles and pete« 
chial fever. We had frequent opportunities of noticing the pre« 
sence of sndamina, which although in most cases they did not 
exceed millet seeds in nse, yet in some were large phlyctenas. 
They did not seem to be accompanied with any symptoms, and 
were generally met with when the skin was relaxed in pers^ 
piration. This epidemic exhibited this striking difierenoe^ 
when compared with other preceding ones, the complete ab- 
sence of anything like crisis. We feel ourselves safe in assert- 
ing, that we have scarcely seen acase in which there has been a 
decided crims, at least such a one as we constantly observed in 
the epidemic of 1826-27, when we were almost sure to have a 



182 Dr. Law^s Obeemaiums on Peoer. 

marked change on the fiflh or seventh day. Novr the disease 
gradually progresses till it has reached its acme^ and then as 
gradually declines^ so that we are ever kept in a state of tremu- 
lous anxiety till convalescence is perfectly established. The 
fever has in general been protracted. From the ciroumstaooe 
of the patient seldom seeking admission into hospital till their 
disease had began to assume somewhat of a dangeroiu oharac- 
ter, we found it difficult in most instances to fix the exact dura- 
tion o( it, but as far as we could ascertain, twenty-one days 
seemed to be its average. We had a single instance in 
which the patient was actually five-and-thirty days under oar 
care before she exhibited any dign of amendment She was 
reported to have been a fortnight ill before admission Into hos- 
pital. Tiiis was the most protracted case of fever we had oyer 
witnessed, in which there was no incidental or accidental inflam- 
mation to account for its imusual duration. In diis case, no doubt, 
there was intestinal heemorrhage, but in no other case where we 
had observed this phenomenon, did we see the disease equally 
protracted. 

Derangement of the sensoriom was a sufficiently constant 
feature of the epidemic, under its various phases, to deserve to 
be Tioticed. At the early period of the epidemic, delirium, and 
that of the most violent kind, ciune on under circumstances that 
we were but little prepared to expect it. Individuals came un- 
der our observation with symptoms of mild fever, and witfi 
nothing in their appearance to give rise to an apprehension that 
any thing untoward would occur, when in the midst of the pro^ 
foundest calm, a delirium came on, in some cases so violent 
that mechanical restraint was required. This o<^curred in the 
case of some individuals whose habits of temperance were above 
suspicion. In some instances the patients had been three or four 
days in hospital before this took place. That this should be the 
case in persons of irregular habits was not surprising, and did 
occur very frequently. In fact, many of these oases so closely 
resembled delirium tremens, that we should have regarded them 



• Dr. Law^s Obtervati&M (m Fever. 183 

simply as such> did not the presence of petechias ideotify them 
with the prevailing epidemic. This sudden outburst of violent 
delirium sometimes came on in the midst of symptoms denoting 
the worst and lowest stag^ of typhus. Among these cases we 
bad two remarkable instances in two sisters situated in dif- 
ferent wards ; their fevers pursued exactly the same course 
in reference to the delirium ; it came on equally insidious- 
ly in each^ and in each was equally violent. These were the 
cases in whidi we derived so much benefit from the combina- 
tion of tartar emetic and opium, generally exhibited in a oordial 
stimulating menstruum. Among the cases of this nature, accom- 
panied with marked cerebral excitement, were some puerperal 
cases. These we found in general to yidd readily to the com- 
bined tartar emetic and opium. Two of such cases strikingly 
illustrated the efiect of this combination. The individuals came 
into hospital under such excitement as to require to be placed 
under restraint They were reported to have been in this ex- 
cited state for several days, during which they had no deep. 
In each case tranquil sleep supervened shortly after the setend 
dose of the following mixture, was taken. 

]^ Mist. CamphoroD ^vii. 

Tart. Emetic, gr. ii. 

Aceti Opii gutts. xxx. 

Spirit Etheri Nitrid 5iii. 

Syrupi Croci 3v« 
Blisce, Bumat unciam tertiia horis. 

In one of those cases the delirium came on seven weeks after de- 
livery. In the interval of delivery and the accession of fever, 
the individual was affected with mammary abscess, whidi we 
suspect, by acting as a counter-irritant, kept the disposition to 
mania in abeyance ; for no sooner had the abscess healed then 
the mania supervened. 

Although perhaps it would be more regular to reserve our 
observations upon a point of practice to a later period of our re- 
marks when we come to consider Uie treatment^ sttil we cannot 



184 Dr. Law's ObiervatUms on Fever* 

leave the subject without noticing the great and decided ad- 
vantage we found to follow the use of the shower bath, either 
cold or tepid, in some of those cases of high cerebral excitement, 
in which we had in vain tried to tranquillize or procure 
sleep for our patient, either by opiates, or the combined tartar 
emetic and opium. In many cases the patients themselves have 
solicited a repetition of the bath, from a consciousness oi the 
benefit they derived from it ; and often have we seen sleep to 
come on almost immediately on their getting to bed. In not a 
few instances the violence of the patient has been such, that 
the strait waistcoat could not be taken off while he was getting 
fhe bath, but immediately afterwards the necessity for it had 
ceased, and in consequence it was removed. Besides the de- 
lirium which came on thus early in the course of the fever, and 
in some instances, it was amongst the earliest symptoms, and 
gave the disease very much the character of meningitis, we 
found it to come on at later periods; ottmi from about the 
eleventh to the fifteenth day we noticed this phenomenon ; and 
from observing it to come so frequendy, when diarrhoea, tymp»> 
nitio abdomen, ilio-cascal, gargouillment and red tongue pointed 
to afiection of the intestinal mucous membrane, we looked 
upon it as the sympathetic effect of this affection : and we were 
soon taught that the abdominal afi^tion required very cautious 
and delicate management; for we remarked, that when the 
diarrhoea was suddenly checked, an immediate aggravation of 
the cerebral symptoms was the almost certain consequence. It 
seemed as if the disease were then exclusively concentered 
upon the brain. Hence, we recognized the necessity of apply- 
ing our treatment to the two sets of symptoms, and with this 
view we applied at the same time leeches to the head and ab- 
domen, behind the ears, and along the side of the neck ; and to 
the epigastrium, (where both the stomach and' the transverse 
arch of the colon shared in the advantage,) to the ilio-csecal re- 
^n, and to the verge of the anus. Besides these means cdid 
btions were applied to the forehead, cataplasms to the ab* 



Pr. I^aw'a Obierv^Hons on Fever. 185 

domen. InsomecMeByoitberbltftersortiwptBliDe 
applied to tbe abdomeo. The medicine upon which we placed 
most reliance in muh ca«e% was tbe combination of hydrargyrum 
c cret&« and Dovef'a powd^iv whidi we neiwr found to check 
tbe diarrhoea prematurely. Before we leave this subjecti we 
fcel the necessity of subjoinhig a caution as to the employment of 
tartar emetu^ with a view to control tbe delirium> arivng under 
the peculiar circumstances which we are at prasent oonsider- 
logi, The state of the bowels plainly contra-indioates it : still 
we have seen it used« and have seen the intestinel aflbction 
much aggravated by it. We have thu% not wftequentlyi had 
occasion to observe^ bow the unseasonable employment otf a 
valuable remedy will entail discredit upon it, because it has 
Mt realised ungrounded and unreasonable expectations, ex- 
pectations based upon the erroneous idea, that the same pheno- 
mena or symptom is ever to be dealt with in the same way, 
no matter what be its cause ; an error which will appear still 
more glaring, when we pass on to the consideration of the 
delirium which comes on at a still later period of the disease. 

One of the strangest circumstances oonnected with disease 
is the fact, that two conditions, not only different but diametric 
cally opposed to each otber>, will give rise to the same pheno- 
menon ; Urns do we see delirium at onoe the result of deler- 
mimtiaq of blood to the brain, as well as of a deficient supply of 
blood to this organ* as in cases of profuse fassmoirhage. Were 
this symptom alone, irrespective of its cause, to guide our treat- 
ment here, into what a mistake would we be betrayed ? But a 
protracted disease, producing extreme debility and exhaustion, 
will have precisely the same effect as the anemic state of the 
brain, it will equally give rise to delirium, and equally require 
a modified treatment The best illustrations of this have been 
furnished us by cases of erysipelas coming on in the progress of 
feven If other circumstances warranted us in the practice, the 
delirium, so for from deterring us from giving wine, was in fact 
a reason for our doing sq» Although we could adduce number- 

VOL. XII. MO. 35. 2 B 



186 Dr. Law's ObiervaHons on Fever. 

leas* cases to confirm tho fact, that thecMiriom under these 
circumstances disappears as the other symptoms improre under 
the exhibition of wine, still we feel that it is one of the points 
of practice demanding a degree of judgment equal at least to 
any other of medicine. ' Indeed in many such oasm the exhibi- 
tion of tHne is an experiment, the effect of which the jdiysician 
should himself narrowly watch, and not leave a discretion with an 
attendant, who can scarcely be expected to be competent to ap- 
preciate the contingencies which should cause the stimulus to be 
increased or diminished, or to be entirely withdrawn. This con- 
sideration lead» us to express oiir persuasion, that the safety of a 
patient in bad fever peremptorily demands the repeated visits 
of the physician through the day ; for changes occur so sitddenly, 
and require such immediate attention, that often a moment lost 
is irretrievaHe. 

We ojflen find ddirium in the form of some particular 
delusion or hallucination, surviving every other symptom of 
fever, and according to its diameter, whether agreeable or 
otherwise, modifying the convalescence. Thus have we seen 
the private soldier {fuming himself on his imaginary elevation 
to the rank of Captain; and the pennyless pauper exulting in 
the fond delusion of having become a wealthy legatee, so that 
when the unlucky blister, applied to the nape of the neek, 
brought them back to ** all the horrors of sobriety,^ each, if he 
did not say it in the precise language of the poet, at least 
thought 

" Pol me occidistis, amici. 
Nod senrastis." 

Again, we have seen convalescence actually retarded by a 
delusion of a dififerent complexion. Thus have we seen a poor 
woman so possessed with the feeling that her husband was in 
confinement for dishonesty, that no means we could employ to 
persuade her to the contrary had the least effect. All the 
symptoms of fever were revived, till we had her husband 
brought, when every thing went on smoothly. We have seen 



Dr Law's ObservaUans on Fever. 187 

imagioaiy pecuniary, losses produce the same effect. A blister 
to the nape of the neck will in genoral (not always, time alone 
efieets it in some cases) set all to rights. 

Of the contagious nature of this fever we have had abundant 
evidence in the way in which almost all the members of families 
have been affected, not cmly those residing under the same 
roof, but also those who lived separately and at distances^ but 
amongst whom intercourse was kept up. We had a remark- 
able instance in seven members of the same &mily, but residing 
in three separate localities, being affected, although not at the 
same time, first the old grandmother became affected and 
died; then her daughter-in-law, living in a different part of the 
city; then her two married daughters, one of whom died ; then 
the husband of this last, and at the same time two children ; 
last of all tiie grandfather, aged 70, was brougl^t into hospital 
almost moribund ; he, however, recovered. 

We alluded, in an early stage of our observations, to the 
occurrence of difilise inflammation in some cases of this fever. 
We have had several instances, and had reason always to regard it 
as a most fatal complication. It exhibited itself at an advanced 
period of the disease, in the form most commonly of tume- 
faction of the joints, sometimes with a slight erythematous 
blush. The knees, ancles, and wrists were the most common 
seat of this affection. In one case of scarlatina this inflamma- 
tion affected the cellular membrane of the neck, and involved 
the stemo-clavicular articulations. In another instance, it ex- 
tended from the shoulder along the neck to the anterior 
mediastinum, and the anterior surface of the pericardium. In 
other cases we found collections of purulent matter in difierent 
parts of the body, not raised into a tumour, but causing some- 
times a scarcely appreciable fulness of the parts where they were 
situated. The constitutional symptoms, which were generally pre- 
sent, were extreme prostration of (be powers of the system, deli- 
rium, small weak pulse, diarrhoea, tympanitic abdomen, and in 
some cases an indescribable anxiety, while in others the patient 



188 Dr. Loir's ObservahoM tm Fever. 

told you be felt fainaelf itiiich better. On examination of ike 
parts afiedted wi& ii^amination, the tumefied joints, in generalt 
contained purulent matter of a tbin, greeniab^unhealtby cbarader, 
and in some cases^ the cartibges were dther in whole or in 
part destroyed, leaving the ends of the bone denuded and 
rough. In some cases the tumefaction was owing to the infil- 
tration of a gelatinous fluid into tbe oeliiilar membrane about 
the joints. When the matter was found in other parts, it waa 
not coidned in a cyst, nor was there any hardening of tbe parts 
from effused lymph in its vicinity ; it was in the strict sense 
difiuse inflammation. 

We would observe that this inflammation occurred in many 
instances after a decided amendment in the symptoms <^the fever 
bad taken place, and when we had every reason to expect a 
fortunate issue. This leads us to make a general observation, 
that in an epidemic the mildeot case is not without danger, nor 
is the extremest case without hqpe. Our prognosis cannot be 
too guarded — for we know not the moment wh^i appearances 
calculated to excite tbe most sanguine bopes> may be disap- 
pointed ; and, again, we have seen casesi where the principle of 
life seemed to be only not extinct, recover under the me of sti* 
mulants. We might remark fliat the period of the eptdemic 
when this untoward complication of diffiise inflammation pre- 
sented itsdf was when post mortem examination discovered no 
afiection, at least ulceration, of the intestinal mucous membrane, 
and certainly it was tbe period when the deaths were most no* 
merous. 

An article of this nature precludes our entering much into 
the detail of treatment Indeed, most of our observations upon 
this point have been anticipated in the progress of our remarks 
already made ; we must, however, give somewhat of a sketch of 
our usual practice. 

The simple principles uppn which we early learned to treat 
fever, and which seem to us to compreh^d almost, if not alto- 
gether, all tbe indications that can present themsdves, are, la^ 



Dr. Law's Obiervatims on Ikver, * 189 

to diminish &e actions or fanetioDs which are in excess ; 2nd^ to 
increase those which are defective : 3rd, to restore the due order 
of succession of those which ha?e had it disturbed. We shall 
first remi&rk on the last of these* As the cause of fever, what^ 
ever it may be, or whatever be the direct mode of its operation, 
changes healUiy and natural inta unhealthy and wnatural 
action; to invert this operation by originating a new hrain of 
actions analogous to those of health, is the principle of cure. It 
is the early period of disease alone, before the morbid habit is 
formed, or the organisation of parts is injured, or taken the im« 
press <^ unnatural action, that the morbid chain can be snapped 
across consistently with safety ; and now decided practices, of 
whatever description, succeed, and complete and perfect re* 
covery of health is often the effect of directly opposite means» 
It randy happens that a case of fever presents itself to us till the 
period when we might have hoped to have acoomjiished this 
object has already gone by. We have, therefore, to ap{dy the 
two first principles of treatment to the unhealthy or umratund 
actions in the progress of dieir development 

Let us now condder the ai^pAication of these two principlet 
to the prominent feature of fever, for instance, to the derange* 
meet of the circulation, and of calorification, which are the two 
iiinctionsmostcommonly and most prominently afiected in fever. 
The actiob or motion of the heart is eithw unnaturally iiK^'easedy 
or in cases unnaturally diminished. The obvious indications 
are, either to diminish or to increase ttie unaatural action, not 
in all -cases by the same means, but by means accommodated to 
the peculiar drcumstances of the individual case. Thus, in one 
case we lower the circulation by bleeding, ia anodiar case by 
pui^gatives, in another case by sedatives, &c. &e. We may ap* 
ply the same principles dther to the elevation or to the lower* 
ing of the temperature, and so, in &ct, deal with almost aU 
the unhealthy actions or functions, the resuUs of the febrile 
morUfio principle. And although we afiect not to say, that all 
the treatment offerer wiU yield a ready sufamiasion to diese 



190 Df. Lbl^^b ObserDotiom imPever. 

sitnple rules^ we can only say, we have ffelt the advantage of 
their application in treating the disease. True, mnch connected 
with disease lies beyond our ken, nature has placed a telum 
interposUum between the precise form of morbid action, and 
our means of ascertaining it ; still there is much which can be 
ascertained, and much too which happily can be righted. 

We shall notice but very few points of practice. There is 
no point upon which medical men have diflered more than upon 
bleeding in fever. We shall only observe, that we were led to 
give it a very fair trial, in an epidemic of a much more sthe- 
nic type than this present one, and from the result, see no rea- 
son to adopt it as a general practice. On the contrary, we 
are quite sure, that we have observed injurious effects from its 
being resorted to only because the disease was fever. 

In the treatment of epidemic fever, and indeed of all epi- 
demics, the fact of the accompanying fever being almost always 
of a typhoid type, has not been sufficiently attended to, and in 
consequence much injury has resulted from a treatment being 
adopted, too vigorom for an epidemic, but which could have 
suited a sporadic case of the same designation. In the recent 
influenza, especially when it assumed the character of broncho- 
gastric fever, we have met with some cases which we know to 
have been seriously injured by active depletion. We conceive 
that bleeding should not be employed in fever, unless there be 
some serious c6m|dication, and in general in epidemics, when 
we can safely, and without temporizing, substitute local for 
general bleeding, we ought to do so. It is needless for us to 
advert to the difierent parts to which we apply leeches in fever, 
these of course must depend upon the particular seat of con*- 
gestion, and to where the blood is determined. We would only 
remark how much relief some patients have derived firom their 
application to the nape of the neck, where they had been dis- 
tressed by headach, especially affecting the occiput, and from 
their application along the spine, where pain and uneasiness 
"were referred to this region, as th^ are so constantiy to the loins. 



Dr. IjBLYr*s Observations, on P^vfir. 191 

We found young females who had become afiected with fever^ 
when the menstrual discharge had been either defective or ab- 
sent^ suffer from most distressing pain, and sense of fulness of 
the head : with these^ leeches applied to the feet, and stupes 
afterwards, yielded great relief. We seldom had occasion to 
open the temporal 'artery* Shaving the head, application of 
cold' lotions to it, and leeches, generally superseded the n^ces- 
sity* We would here testify our complete assent to an obser\*a- 
tion made by M. Andral, on cold lotions applied to the head, 
viz. that their continued application has sometimes an ipjurious 
effect, producing torpor of the brain. Thi3 effect we have seen 
exhibiting itself in a general chill, cold feet, we&k pulse, &c. 
We therefore in most caees direct the occasional sponging the 
head. 

Did the limits of the present article permit, we should 
gladly detail some cases to illustrate their exclusive and entire 
treatment by stimulants. In many of these cases the patients 
were brought under our care with the entire surface completely 
covered with petechise, in some instances with a cadaveric cold- 
ness, and a pulse scarcely perceptible. Here the single and 
simple indications were to support the ebbing powers of life, 
and to restore the temperature. Some of these cases resembled 
so much cases of cholera, as far as the failure of the circulation 
and calorification went, that had they occurred at a time when 
this disease prevailed, they might easily have been mistaken. 
Most of these cases recovered by a free use of wine, and in 
some cases of brandy ; with these we associated our hospitajl 
fomiula of cardiac mixture composed of camphor julep, carbo- 
nate of ammonia, and Hoffmanns anodyne. It was quite re- 
marfcaUe the quantity of stimulants some cases actually required 
before we could feel a pulse at the wrist. The difficulties of 
the ease only now begin ; it is now that discernment is required 
to regulate stimulation. Hitherto there was no fear of domg 
too much. Now the apprehension arises, lest action be exerted 
begrond the powers of the system to sustain it, and be followed 
by a degree of languor proporUonate to the- degree of the pre- 



192 Dr. Law's ObiermUons on JRfver. 

ceding exelteoieiit, stiU the impreisum made nuut be supported. 
To regulate stimulation^ to come up to Mid not go beyond its 
due pointy not only exhibits the nicest exercise of medical skilly 
but in many cases demands the closest vigilance and watd^g. 
For in many cases it is utterly impossible to gauge the precise 
quantity of the stimulus which may be requisite^ its effects alone 
being the regulating measure of it. This is^ perhaps^ the point 
of all others which> in the treatment of fever^ imposes on. the 
physician the necessity of seeing his patient at short intervals. 
When we have made good our ground by sthnulants^ our object 
now is to withdraw them, but not suddenly. With this vidw^in 
addition to diminishing the quantity of wine, we dilute our car- 
diac mixture ; then substitute for it camphor mixture, With aro- 
matic spirit of ammonia ; then for this we substitute effervescing 
draughts with aromatic spiritof ammonia. A modification of this 
treatment is what we found applicable to the generality of cases. 
We tried the chloride of lime, and soda, but cannot say that we 
found them answer the expectations wiiich the accounts of their 
great benefit in fever would have led us to expect ; nor did tiiey, 
when exhibited in the early period of the appearance of petechi^^ 
Seem to check their further development 

Although here, perhaps, would be the occasion for us to 
make some observations on the exhibition of opium as we em - 
}doyed it, we feel the subject would require us to say more than 
would consist with the limits of this article. We would also ob- 
serve that it is, periiaps, one of the points of delicate management 
of fever, upon which it is extremely diflScult, if not utterly im« 
possible, to lay down any approximation to general rules ; ex«> 
perience, and it alone, will suggest Its timely exhibition. 

We have already adverted to the combination of tartar emetic 
and ophim, exhibited in the delirium of fe^r. For a series of 
yean we had employed this combination in the treatment of de- 
lirium tremens; and in some cases of fever with delirium of 
somewhat a sitnSar nature we had also used it with like suc- 
cess ; but about two years since it was, that multiplied cases of 
fever, exhibiting a striking similarity to delirium tremens af- 



Dr. Law's ObservaHom <m Ffper. 193 

forded us an opportunity of more extennrely employing it^ and 
of being satisfied of its value. We cannot afford space for more 
than a mere allusion to what we have more fully detailed in a 
clinical lecture delivered by us in Sir Patrick Dun*s Hospitali 
and reported in the London Medical Gazette, No. 40, June 2nd^ 
1836. We there remarked, that observing irritation and con- 
gestion to constitute as it were the two pathological elements of 
the cerebral affection in delirium tremens, we were led to em* 
ploy a combination of remedial agents, whose influence would 
be directed a^nst each element of the mixed affection, and 
apportioned the quantity of eaah ingredient of the comUnatipn 
to the degree in which the indications of irritation or congestion 
predominated. The combination we employed consisted of 
tartar emetic and opium, the former directed against the conges- 
tion, and the latter against the irritation. When die irritation 
and congestion seemed to co-exist in an equal degree, the in- 
gredients of the combination were adjusted accordingly. When 
the irritation existed alone, or if there were any congestion, it 
was so inconsiderable as scarcely to shew itself, a mere frac- 
tion of tartar emetic was admitted into the combination, the 
opium being proportionate to the irritation. When, again, the 
congestive symptoms were so prominent as to Hiask those of irri- 
tation, then the tartar emetic was employed, nearly, or altoge** 
ther to the exclusion of the opium. These conditions seemed 
to embrace almost all the modifications that were presented to 
us whether in delirium tremens or fever, and we found that « 
careful adjustment of the remedies met the indications. In 
two cases which have just been under our care> we exhibited 
the tartar emetic and opium in a stimuli^ing menstruum, with 
most marked advantage. Tranquil sleep, after most protracted 
absence of it, followed in each case after a very short time. 

Before we conclude our observersations upon our practice 

in fever, we would remark, that although in no respect is the 

treatment pf this disease more improved than in the exhibition 

of purgative medicines, still, too much of the old system of 

veu XII. NO. 35. 2 c 



194 Dr. hetif^ O^fmtUms on Fever. 



daily purgation, And Aatby tneatis of tftitmg diWde eaUiarlk!^ 
continues, and brings its injurious effects under our ohMrration^ 
There are two kinds of ferers, in wbidi, espeekHy, w6 hate 
noticed pemieious consequences rteulting from Hbth praelice i 
one, in which the gastro-intestinal muoouB membrane has a teiH 
dency ta inflammation, and in which, although a diarrfacsa most 
commonly exists^ still not always ; and when it dees not, a pur^ 
gative will be sure to produce it{ the other is a low netvous 
fever, in which the operatkm of even a mild cathartic is attended 
with a considerable d^ree of physical exhaustion. The jodi«* 
cious treatnaent of Uiia lasA consists more in withheMiiig thatt 
in giving medicine. 

The post mortem appearances ftat #e have Imd occasion io 
observe have been very various. In some cases^ and in whiek 
head symptoms predominated during life^ we have not only met 
with the congested stste of iht large superficial veins of tihe 
brain, the opaque thickened appearance of the arachnoid, an 
unusually dotted condition of a transverse section of the organ, 
but have seen as extensive an eflmon of fluid into the ventricles 
and upon tlfe surface of die brain, as if they bad been eases of 
pure hydrocephalus. 

In cases where the chest seemed to be prineipatly engaged 
dfuing life^ we found in general the paronchyma of the organ, ti> 
a greater or less ^xt^t, in a state of engoument or congestion, 
varying from a dark blackish appearance resembling a softened 
ipleen, to the reddish vermilion hue of red hepatisation. In 
general, ih^ bronchial tt^mbrane was highly injected, and yoft 
could easily follow the bronchial ramifications, exhibitittg ihm 
Vascular condition of their lining membrane, into the congested 
parenchyma in which they 'were lost When pneumonia had 
existed in its third or suppurative stage, more or leM of tbt 
organ was solidified, w» of an ash gray colour, and easily ad- 
mitted of being broken down. There vras a sparing exudation 
of purulent matter, when a portion of it was preteed. in seine 
cases ^is change of structure bad invaded nearly 4be whole of 
the organ, in others it was confined to a single lobe; but,' our 



Dr. I^w's Obiervations on Fever. ;I9S 

gBoettJ obaenratioi^. w^^ that it more, frequent^ engaged the 
4ipp«r part of the liu^ ; and this we had occaaion to observe in 
many cases tljiat completely recoverecl. We are at a loss to con- 
j/ecture^ why the 9pex of the lung should in this case, as in 
phthisis* be the favourite seat of the lesion, and not the ba^e or 
posterior part;, lis in ordinary pneumopia ; aootlier reason, with 
many, to eonvince us of the essentially difiereut nature of the 
affection from common pneumonia^ 

Soipe cases, in whidi there was obstinate vomiting during 
life, exhibited the mucous membrane of the stomach moris or less 
jkycMct^ ; and in one case in which this symptom could not be 
contrcUed, this membrane exhibited an universal suffusion or 
.crimson blush, ^d wos so soft and pulpy that it could be easily 
detached and scraped off. The aberratipns of this membrane 
irom its normal stute, were more in its consistence than colour 
jiod vascularity. 

The dw>denum seldom presented ^ny unusual appearance. 
^The remaindei: of the small intestine was generally more or 
iesa ccKigest^dy the capillaries situated in the loose submucous 
4i9sae easily Emitting of that congestion which was every 
where to be seen, and which appears to us as much entitled to 
give tho designation of gastro-enteritis to fever^ as the injected 
ftate of the capijl^ries of the ^kin i^^ould be \o give jt (he ^mg- 
nation of dermaikis* 

When the mucous membrane of the small intest'u^e has been 
deeply enp0^, we can in geperal detect the situfition of the le- 
^oxk befoi^ we open tb^ injtestine, by a d^k appeig-ance which 
.it fvesents eKtem^lly, and by a thickenmg which is palpable 
jvben the p^rt is felt between the fingers, Tlie l^on is generally 
Mnfined to the last portimi of the ilion. We first detect a patch 
jof small glands clustered together, and affecting various shapes 
^d fornifi, sometimes longitudinal, sometimes circular. Thes') 
i^ysters of gj^nds or follicles presented very much the c^ppear- 
nme fis if the poiitioo of the mucous fnembraae, where they were 
4)itiwM> W^ Fptised by some aub^stiwce pl^uced undempath it, and 



196 Dr. Law's Observations on Fever. 

was then perforated by a pin. This seemed to be the first 
stage of the lesion, for this was the appearance ifirhich we met 
with in cases in which death had supervened very quickly, 
before time had been allowed for the complete disorga- 
nization or lesion. When we approached nearer to the termi- 
nation of the intestine we observed elevations resembling vari- 
olous pustules with small ulcerations in their centres ; then 
we met with true ulcers, either circular or elliptical in their 
shape, with the denuded muscular fibres plainly to be seen 
at their bottom. The nearer we approached the termination 
of the intestine, the nearer were these ulcerations to each 
other. They most commonly occupied the convex portion of 
the intestine, in reference to its attachment to the mesentery. 
Next to the coecum, and on the margin of the ilio-coecal valve 
there was generally a large, irregular, sloughy ulcer, commonly 
besmeared with bilious, excrementitious matter. It was some- 
times quite astonishing to witness the extent to which the 
mucous membrane had been destroyed, and how little notifica- 
tion there had been of it during life, and also to see how near 
the ulcer was in some cases to perforating the intestine, without 
doing so. In general the vessels of the mesentery were 
very much injected, and the glands situated near the ulcerated 
intestine large, and when cut into, presented a red fleshy ap- 
pearance. The congestion generally extended to the coecum, 
but not much beyond it. 

We would here advert to a singular appearance presented 
in the case of a woman aged 40, who seemed never to rally 
aftef the first moment of her being seized with fever. There 
was a complete collapse of all the vital energies; the appear- 
ance to which we allude, consisted in an infiltration of air into 
the sub-mucous tissue in difierent parts of the small intestine^ 

a 

from the duodenum to the ilion. The body exhibited no other 
remarkable appearance. Was this putrefaction, or decomposi- 
tion, anticipating dissolution ? In almost all our examinations 
we were struck with the fluid condition of the blood These 
morbid appearances were what we most frequently met witb^ 



Dr. Lendrick an the Use pnd Abtue of Mercury. 197 

yet we could adduce cases In which air the most prominent 
features of the most aggravated typhus were present, and stilt 
examination could discover no lesion upon which to charge the 
severity of the symptoms. We would conclude our remarks by 
observing, that if a close and careful examination^ of this subject 
has not taught us what fever is, it has at least taught us what it 
is not ; that it is not gastro-enteritis, nor entero-mesenteritis^ 
nor dothinenteritis, but a disease sometimes modified by local 
lesion^ which is an accidental complication^ but not an es- 
sential condition. Or if local' lesson be essential, it must 
be confisssed it is of such a nature as in many and tfie worst 
OEises to elude observation and detection. It has also allowed 
lis to see that it is rather impatient of the restraints that sys^ 
tematic medicine would impose upon it, and will not submit 
to them. It ftirther telb us that the physician who would really 
understand disease, must be satisfied ever to be a learner; that 
he can never fold his arms and complacently rest upon his stored 
up stock of information ; he must be ever adding to it ; he 
must ever continue to read Nature's page, which is ever changing 
and ever varied. Medicine and medical science have at least 
this attraction, that tfiey have always some&mg new wherewith 
to repay the labours of their votaries. 



Art. X. — Observations on the Use and Abuse (fiiercury. 
By Charles Lbndrick, M.D., T. C.D.^ King's IVofessor of 
the Practice of Medicine, Clinical Lecturer in the School 
of Physic, Physician to Mercer's Hospital, &e. 

In my former observations on the use of the nitro-murioHc 
add bath,* I dwelt especially on its efficacy in those venereal 
cases^ where circumstances prohibit the administration of mer* 
cury. I shall now proceed to consider more in detail the ope- 
ration of the latter powerful remedy, premi^ng that there is much 



• See Dublin Medlad Joaroal for lisy, 18S7. 



198 !>r. Londrtck MthH Use and Mtme ifihrcurt^ 

wfaicfa I bate l«anied fron isxperieiioe, tbtt oftiers have tlerifed 
from a similar source, and ^perhaps communioaled ; so that I ky 
no elaim to originalHy* It is iiiy objeot to dured a^eniiom to 
several important practical points, which, from the Tariety of 
occupation, may be insufficiently conttdered by many ^membcfs 
of ^ profession. 

A controversy exists at the present time, (see the last imm^ 
ber of the Medical Journal,) as to die daims of mereiirf to Ifat 
name of a specif in Tenerori oases. I do not think that die 
eanse of meidieal soienoe has been much advaaeed by dwdling 
M fmmes df any kind ; more espeaially as we often find that 
dispulanta about words do not very aiMilmidly differ as to thetr 
ideas of the ^filings signified. That viM^cury is adapted to all 
fbrms and stages of the veoereal dkokai, I believe no one irt die 
present day will conCead for ; but although it has a very martied 
ieSuenee in otber diseases, its eSecte in fomQurabk cases of sy. 
phtUs are so mttch more so, as to render the term ^^ specific'' 
eAnoal applicafaie. 

Deaorihing the meremrkd dimase^ Mn Matihias says, (page 
aSy) ^ It is a dieeaae that mostly takes place during the eouree 
ef another oomptaint, or at least when that complatiit is under 
cure, and therefore very liable to be eonfounded widi it. In its 
symptoms it strongly resembles the previous disease." 

Mr. Hunter and the late Mr. Todd of Dublin^ have graphi- 
cally described two distinct and opposite operations of mercury 
on the constitution ; ftie one characterized by its visible effects 
oh the secretory and vascular systems, the other on the nervous 
system, the ibrmer generally beneficial, the latter always inju- 
rious. From these extreme influences of mercury, we might, 
even in the absence of more precise information, anticipate a 
considerable variety of intermediate operations on the system^ 
producing changes beneficial or the reverse, according to the 
form and stage of existing disease. As to the eflbctjs of mer- 
cury during a state of perfect health, and freedom from both 
general and local disease ; it is a &ct upon which our informa- 
tion is necessarily defective, as it is no easy matter to find per- 



Dr. Leodrkk on the Uh and Mute of3^4unf. 199 



sons fool-bardy eooii^ to use merciiry for the mene purpose of 
experimeDtf or of enabling pathologists to record the mode of 
its operation. 

The symptoms of the morbid operation of meraxtj on the 
sy4em> aie described faithfully by the authors I ha?e roen«* 
tiooed, and by others. In many eaaes^ however, where meraury 
does not disagree suffioieiilly to di^lay those ^mptoms in the 
cim^ti^ifltoiiy or ivhere thq|t hsprenotyet had time (0 deiie^i them« 
selves, it manifests its operation on iheweiApart, that4abonring 
imder, or predisposed to disease ; and thb geneeally with a 
foree proportional to its salutary inflaenoe on that disease where 
mercury agrees with the system^ If the wamiag from this ag«> 
gravation be not taken in time, and mercury be persevered in^ 
the eonstihOional symptoms of its morbid influence become ma* 
nifest, while the disease fior which it was administered assumes 
a new form, and becomes neariy, and sometimes akogelher mK 
controllable by remedial measures. 

For instanooy the salutary effect of mercury in some diB^ 
eases of the livery especially in hot climates, is so universally 
conceded^ as to nearly entitie it to the name of a specifbias for 
aa they are. concerned. Yet there «b many affections of thi# 
organ, and even stages of that in which it is usually beaeficialv 
where, instead of removing or preventing disorgansxation, it 
proves its eautCy and the patient sinics into a state of Boaninnus^ 
generally followed by death. 

Dr. O'Beime* has directed the attention of the profiMsion to 
^ powerful eflScacy of mercury in aente afieetions of the 
jcmUi yet how often do we see painful sMlingsof the articu^ 
lations, with copious effusion into their cavities, emtdng on the 
adminislratioB of mercury for other diseases, and where the 
predispositioa to any affection of die joiirt was previonsLy ao 
slight as soareriy to have attracted attention. , 

"Iliere ane, perhaps, few diseases fdiich receive more de^ 

• DabliaMtdioal J«tfh»l, Uky, 1834. 



200 £hr. Lendrick on the U$e and Abu9e iif Mercury. 

cided advantage from the judidous admioistration of mercury, 
than dysentery f and yet^ if the morbid influence of the remedy 
should display itself during the treatment of this disease, it will 
prove its aggravation instead of its cure. The reader will find 
this circumstance referred to by the late Dr. Cheyne,* and it 
is remarkable, that in the cases wbers mercury proved prejudi- 
cial, there was evidence, from the state of the gums, and from 
constitutional symptoms, that an anomalous action of the re* 
medy had taken place in the system at large. 

Many other instances might be adduced of this somewhat 
homceopaihic action of mercury, which is not, however, peeu* 
liar to it. Among other remedies, opium presents an exem- 
{dification. Opium is one of the most powerful means of coun- 
teracting diarrhoea; yet in that depraved state of the con^to- 
tion appertaining to opium eaters, diarrhoea is one of the moist 
usual symptoms. From the great variety of diseases, however, 
in which mercury is applicable, its influence this way is espe- 
cially marked ; and as it is found that the more q)ec^c the 
beneficial operation of mercury on a disease is, the more deci- 
ded are its morbid effects ; we cannot be surprised that the 
phenomena are more clearly developed in syphilis than in most 
other maladies. 

It would, I think, considerably tend to clear our ideas on 
the operation of mercury, to bear in mind that its effects on a 
large scale in quicksilver mines and elsewhere, deariy entitle it 
to the denomination of a poison, although a more slow pne than 
arsenic or other minerals. This consideration does not militate 
in the case of the one more than the other, against the opera- 
tion being beneficial where it is kept within bounds, and ap- 
plied under favourable circumstances. It shows, however, 
that we ought not to b^ so much surprised as we frequently 
are, at mercury disagreeing ; its disagreement with the humiaR 
4X>nstttutioii being, in fact, the rule, and its. favourable opera- 

# DobUn Ho^tal Reports. 



Or. Leodfiek on the Use and AJm$e of Mercury. 201 

tion the esiicepUan, ttid not inde ver$i, as wo are too apt to 
suppose. 

In administering mercury in Tenereal^ nul indeed in most 
other cases^ it is to be also borne in mind, that the gradations 
ftom its beneficial to its morbid operation are extremdy uncer. 
tain. Sometimes mercury is found gradually to disagree^ and 
having proved salutary for a time^ it then fails, and finally proves 
injurious. In other eases, the transition is rapid and decided 
from the one stage to the other ; the disease for which it was 
administered having been in a progressive state of recovery, and 
becoming suddenly exasperated without apparentiy any station- 
ary period. These facts ought to make practitioners especially 
cautious to sdect the proper stage and the proper mode of ad« 
minifltFatioo. A^ very slight error as to either, or as to the con* 
tinuanoe of mercury for even a very short time beyond the pro* 
per period, may lead to irreparable misdiief. 

When the morbid operation of mercury takes place during 
the treatment of venereal cases, there seem to be two modes 
10 which it displays itself. 

Ist The existing ^mptoms, whether primary or secondary, 
become aggravated*-»and often considerably so, before there is 
any proof of its disagreement with the constitution. Ulceration 
qpreads, and becomes malignant ; unhealthy inflammation, fol- 
lowed by gangrene, attacks the nei^bourihg parts, and new ul* 
eecs appear in their vicinity. If mercury be continued, and the 
local destructive efiects are not sufficiently marked to deter the 
practitioner, its, morbid influence on the constitution becomes 
apparent, by some of the symptoms detailed by Hunter and 
Todd» In some instances, however, we find, and that even in 
the treatment of the primary disease, some derangement of the 
general heaiih, preceding its morbid action on the part, and 
from which we on^ to take warning in time. I have known 
cases where the warning was not taken, and mercury pushed 
imly a liUle too far, with most deplorable results. I attended 
<a gentleman for primary symptonas some years since,, and who 

VOL. XII. NO. 35. 2d 



202 Dr. Lehdrick on Ihe Use and Abuse of Mercui^y. 

4iad previoirsty lost a portion of Ihapc^is from sTovighing during 
a former venereal attack, (mercury naturally disagreeing witli 
his constitution,) ami notwithstanding that the ulcera^tion was 
small, and that tlie case was treated from the first with every 
precaution as to regimen, &c., the cure occupied upwdrds of 
four months, so frequently did the morbid altenmte with .and 
super^e tlie favourable operation of mercury ;* the consiitu-i^ 
tional symptonis of this morbid action sometimes taking prece^ 
dence of the local, and on other occasions, an tmiavourable 
change in the latter leading the way. No secondary symptoms 
ensued. Perhaps it will be said that the case ought to have 
been treated ;2(»z-mercurially ; to this, however, I am.certaiQ the 
patient would not have consented, as he said the administratioD 
of mercury, from which he before suffered^ had become nece&* 
sary in consequence of a previous non-mercurial attempt. ' 

2ndly. Mercury, when acting injuriously, attacks parts jw^r 
disposed to the venereal disease ; of this the most obvious in- 
stance is, the occurrence of secondary chancres, at the close of 
the treatment of the primary, or while the patient is using mei^ 
cury for other secondary symptoms. It also has a peculiar ten* 
dency to accelerate the disease in those predisposed parts, and 
often in an aggravated form. Thus we find symptoms called 
by some venereal, by others pseudo- venereal, and by some mer* 
curial, breaking out in the throat during the treatment of a pri« 
tnary chancre, and long before they could be expected to occur 
Bpontaneously as secondary symptoms. Disease in the perios* 
4eum and bones^ called -by Hunter "the last order of parts,'* 
will often take place, and often in an inveterate form, during 
the merciirial treatment of what are considered as early eecon^ 
xlary s3rmptoms ; and T have seen a chronic swelling and indu* 
ration of the testicle, which is usually a late occurrence in 8|y|Ai* 
lis, preceding all the other secondary symptoms. This led tli€ 
sagacious Abeniethy to consider all such venereal symptoms as 
occurred f ' out of their order*'-— as pseudo-syphilitic, or at least 
*not to be treated with mercury. It is, however, to be recok- 



Dr. Len^ick on the Use and Abuse if Mercury!- 303- 

lected^ that the homoeopathic action of mercury is only dis^' 
played i^ predisposed parta^ and I quite ligree with Dr. Colles, 
in never having witnessed nodes^ or any other apparently vene- 
real symptom produced by mercury in aii untainted constitu- 
tion ; although in that contaminated by syphilis, these and othei* 
sjrphilitic symptoms will take place, earlier and more severely 
in consequence of ihe administration of mercury, and of its un'^ 
favourable operation on the system* Sometimes the favourable 
and.onfavoureble operations of this remedy are so intermingled, 
or the lattftr so slightly developed, that while mercury seeing td 
produce new synaptoms, it; appears to be curing others. In thi^ 
<»se, the safe rule is, rather not to do good, than to commit 
positive harm, llie suspension of mercury may seem to delay 
the cure, but it may prevent the necessity of discontinuitig the 
remedy altogether, and thus be the means of saving instead of 
losing time, by only lessening the beneficial, while it removes 
the morbid action. 

The treatment of those venereal cases in which mereury lias 
been either not used at all, or so slightly as to produce on the 
entire neither a favourable nor unfavourable effect, (und for 
practical purposes the cases may be considered as the same,) is 
plain sailing, compared with that of the disease wliere mercury 
lias been abundantly used in vain. In the latter, we are sur- 
prised to find the patient with well marked symptoms, (primary 
or secondary,) while he has taken treble the ordinary quantity 
of the medicine. This surprise is the consequence of adopting 
4bo strongly the opinion as to the quantity of mercury neces- 
•sary. Taking, for instance, three ounces of ointment, or about 
forty frictions as a pretty fair allowance, we find that half a 
•pound has been used in vain. But if it be recollected, that dur- 
ing three^fourths of the time, perhaps, mercury was acting inef- 
ficiently or injuriously, we have a right to reckon only one-fourth 
of the half pound or two ounces, as being beneficially used; 
And against this» we have to set off at least ^ome morbid action, 
aggravating old symptoms, and accelerating .new ones, and 



204 Dr. Lendrick on ^ Una and Alm^PfMefeuarp 

vbicb, even under the most judicious management^ nmst hav^ 
oocurred during the administration of ibe remaining three- 
fourths of the mercury. So that on the entire> matters vouUi 
have beeil better by the use of two ounces than of the hal( 
pound. By using mercury ** off and on/' laying it aside with 
reason, and resuming it without it, it is surprising the quan*. 
tity that can be crammed into^omeconstitutioiUj doing no goodj 
and sometimes not much harm* 

In judging, howeyer, as to the morbid efl^ts of mercvBry; it^ 
is to be remembered that aU its evil eonse(|uences are not ne-) 
cessarily displayed during its administration. These sometimee 
seem to commence weeks, or even a longer time, after it has 
been lald-aside, and pursue an obstinate and intractable course^ 
Under such circumstances, the patient frequently charges his 
medical attendant with having discontinued mercury too sooo^ 
and lays the blame on a too ^ring administration of the aiitit 
dote. If the latter act on such suggestions,, the desthiction of 
the former is no unusual consequence. The practitioner tciay 
rest assured, that such venereal symptoms as occur soon after, k 
course of mercury, are not to be benefited then by its admini8» 
tration ; and the probability of such a dilemma as consequent 
on its over administration, ought to make him very careful to 
lay aside mercury in any doubtful case in time. 

Where venereal symptoms are thus brought out by mercuiy, 
they generally pursue one of two courses, if they do not prove 
fatal. 

Ist. If mercury has been laid aside in time, and the practi* 
tioner has not confounded its aggravatory influence with the ordi* 
nary course of the disease, and especially, if appropriate anti-ve- 
nereal treatment (independent of mercury) is resorted to ; these 
symptoms appear to subside ; and then if (as is often the case) 
they do not re-appear, it remains a question, whether the bane 
has not been also the antidote ; that is, whether mercury lias 
not accelerated such symptoms to cure them, or at least to leave 
them curable by other means. 



Df» Leodrick an the Use and Abu$e ofMsrcury. 205* 

2odly« If mercury has not been left offat th6 pr^iste time, or 
rather^ if its injurious operation has not been rather anticipated 
than waited for, these symptoms pursue a tedious and vexatious, 
course^ They become mitigated under non-mercurial treatment,- 
and alternately present inducements for resorting to, and laying 
aside that remedy. At length the patient (if he live long enough) 
gives up mercury in despair, is relieved for a time, and finally 
submits to '' a course,'' and is cured. 

In judging in one of those difficult eas^ where mercury has 
been copiously administered in vain, as to the propriety of its 
exhibition, there are many points to be taken into oonaderation, 
besides the state of the general health, (t^Mfep6ncIen%.of syphi- 
lis,) scrofulous predisposition, the frequency of Uie pulse, ftc- 
Have the symptoms broken out or been aggravated during the 
active adminisiration of mercury ? have ItW, and anti-mercu- 
rial treatment been allowed fiur play, so as to strip the complU' 
cated disease of its mercurial chiiracter ? If the former ques-^ 
tion be answered in the affirmative, and the latter in the n^a^ 
tive, we may be assured the time has not yet come for using 
mercury with advantage. 

In such cases, (as I mentioned in the former papei^,) every 
effort ought to be made to relieve the patient by air, diet, sarsa- 
parilla, acids, hydriodateof potash, aoid baths, &c., so as to d^ 
fer as long as possible having recourse to mercury. The longer 
it is delayed under such circumstances, the more likely it is to 
Mt, The sooner it is resorted to, the more likely it is to fail. 
In administering mercury, the precautions detailed by Dr. CoU 
lea, so necessary in cases of primary syphilis, are quite indispen^ 
pable h^re. Even in ordinary cases, it is but one step from 
safety to danger; but the interval becomes fhrther diminidied^ 
wherd mercury has already failed. Hers the best, the very 
best mode of administration is alone justifiable. In some casei^ 
an alterative course of corrosive sublimate, or of some oO^er 
mercurial preparation, in small doses, succeeds. At any rate 
it is the best preparation for the fiiller administration of mer^y 



20& Dr. Lendrfoli on the Use arid Abuse <>f Msreurj/J 

cury, as if it be. foimd to disagree, we may rest assured that we 
oannot press mercury at the time.* If, on the other hand, the 
symptoms be found to hmend up to a certain point, and the pa-*' 
tient's constitution has improved under the alterative use of the' 
medicine, whilst the disease has become nearly stationary, a more 
i|iU administration of mercury may be ventured .on. If a slight 
s^Ieotibii of the moutfi take place> it will generally be Rodent to 
await its effect on the system and on tlie disease for a few 
days, and not to oosftinu^ the merdury for the purpose of keep- 
ing up its action. In the attempt to do so in a debilitated con- 
^itution, we incur the risk of going back instead of forward in" 
the cure. The affection of the mouth ceases, or becomes mor- 
bidly modified^ and the symptoms retrograde. This first actioir 
of mercury on the mouth in debiUtated cases is seldom 6onsi- 
derable, and yet very important It may be generally consi- 
der^ as an indication for laying the mercury aside, and watch-* 
ing the result, a(Wr which it may be again had recourse to* 
with greater confidence. 1 know that some experienced prac* 
^tioners prefer " keeping up'* this first action of mercury ; and 
the attempt may be justifiable, if the constitution will stbnd it^ 
^hich it w;ill rarely do in the caseis I am considering. On the 
contrary^ so sudden is the gradation from the healthy to the 
morbid action of mercury, (and, I am sorry to say, not vice versd,) 
tliat an amendment of the symptoms, with a slight demonstra* 
tion from time to time of the sensible action of mercury, on the 
system, is all we can hope to accomplish. More would, doubt* 
less, be desirable ; but in the attempt we run the risk of foun- 
dering altogether, lliis use of mercury may be oiUed the 
intermediate between the alterative, and what is termed a full 
course^ If the patient will not bear it, he will not bear the lat- 
ter... It may cure the disease, or, it may go a certain way, and 



* It will be seen, hereafter, that a briiif though powerful action of mercury may 
be borne under such circumatanoes. I am here referring to the tlow constitutional 
at oempaied with, the aUemtWe administration. • ^ ^ 



Pr. Lendrick on the Use and Ahme of Mefcftry. 207 

demonstrate the capability of the patieiit to bear a tfiore acti?^ 
use of mercury. Our practice with this powerful and dangeroui 
remedy, in such cases^ must b^ in a great degree tentative^ : 

I have before* mentioned that the efficacy pf sarsaparilla, 
&c. in syphilis^ is mainly attributable to their' counter-influence 
over the morbid action of mercury. If so, it might be presumed, 
that what has a remedial, must also have a certain amount of 
preventive influence ;.and that it would be advantageous, espe^ 
cially in cases where the morbid action of mercury is much ap^ 
prehended, not merely to exhibit sarsaparilla, antimonials, &C4 
whilst mercury is laid aside, but also during its exhibition. Thi9 
practice is too much neglected in general. J have myself had 
recourse to it with decided advantage for many years : aod I find 
that it is strongly recommended by an almost incontrovertible 
authority. Sir A. Cooper — (Lecture 65.) Dr. Wallace, informs 
me, that he has with great success comlnned the administration 
of the hydrio^ate of potash (for the utility of which jn venereal 
cases we are so much indebted to him) with that of mercury. 
Any thing which will in the slightest degree better the operation 
of mercury is of importance, for it may turn the balance between 
its favourable and unfavourable operation. i 

If we are by judicious management, by continuing mercury 
while agreeing, and by discontinuing it on any doubt occurring, 
so fortunate as to remove the existing venereal symptoms, our 
mercurial treatment is over for the time. New symptoms, or 
the recurrence of the former, may render mercury again neoesf 
sary ; but to continue mercury after the disappearance otsecon.- 
dary symptoms, is a practice inefficacious as t^ preventive ; while 
ihe risk is incurred of causing a recurrence or new form of the 
(disease by the morbid action of the remedy, if itshofdd^tisJs 
trery likely, disagree with the constitution. - -i 

We sometimes meet cases where the venereal disease appears 
to advance steadily during the intervals of the use of mercurj^ 
*i ■ ■■ ■ ■ ■ I ■ ' ■ ' ' ' ■ I II I I I I III 

* Dablio Medical Joanial for May, 1837. 



SOS • Pr* Lendrick on ths Use and Abuse 0f Mercury. 

partly periia{>d qMntaneously^ and partly from the dregs of (he 
mercurial actioa. On having recourse to mercury^ it seems to 
receive a temporary check, but the medicine again disagrees, 
and the patient is worse off than ever. This happens chiefly in 
scpoftilouai* constitutions^ that will not bear the mercurial action 
Ui^9 although they bear a considerable amount of it for a short 
time. In eases of this kind we often succeed by laying mercury 
aside altogether^ and having recourse to non-mercurial treat* 
ment> sarsapariUa^ tonics^ acids^ &c. and then bringing the patient 
tapidly and briefly under the influence of mercury. I admit 
that the practice is sometimes precarious^ and hence every pre- 
caution should be taken to insure the beneficial action of tha 
remedy. Blood-letting should precede, if any inflammatory 
action be present, together with the warm bath, cicuta, and anti* 
IBOnials. The patient should now be confined to bed, and three 
grains of calomel, with half a grain of opium, exhibited every 
four honrs. If we are apprehensive of the action of mercury on 
Ae bowels, half a drachm or more of the ointment may be rub- 
bed into each of the axilla? and thighs, (from two to three 
dradims in all,) night and morning. Thus the system will, in 
thirty-six hours probably, be brought under what is called ^' die 
salotar/' operation of mercury, although it has previously only 
teased die constitution. As considerable danger might ensue, 
should mercury not hit, the practice is only to be recommended 
where mercury cannot be used otherwise, and yet cannot be done 
without A mercurial salivation will sometimes remove tbe ve^ 



* Doctor Collet connden that ia scrofuloas coostitutiotis mercary may be 
ffoAeA ao at to produce ptyafism ia a short time, although preriously gitea fo^ 
a Jeng period in altSrative doses io vaio, or iajorioeslj. I oaaoot Sttbscrihe, 
however, to the opinion, that the use of mercery mi^ in general be oontimud wttli 
safety under snch circumstances. Dr. Ozaves, in describing the meroorlal treat- 
ment of p^^titf, and some other scrofulous diseases^ adverts to the distinction be- 

* 

tween prod«dhg and htepittg up inercurial action in a scrofulous constitution. The 
success of the Ismer in hj f d r o eqf ha hu, is a snflteienr confirmatioli of the correcf- 
aesi of his views. 



Dr. LeAdrfck an the' Use find Abuse bf Merdury. 369 

nereal aymptotfi9 ellogattier, and otemonally only t^iue them to 
ctoppea^ temporatily. If they rdour, they ^re to be viel anew. 
Ob tK> aeeoant should aoy attempt be inade td ke0p tip the oe-: 
li^a of tneroury under soeb eilPcumstanoes^ by its cotitiBUed admi^ 
liiftratioiif. So considerable a- sho^^k is given to the system by 
4be ibroible operation of the vemedy, that the l^asi further \m^ 
latiaa will often sink its powers altogether. 

I not long since admitXied'a' patient into Mercer's Hospital, 
•p^rentiy suffbcaluig from qroancbe* I found that she had 
beet)' using memurjal pills (sf)parently j^idiciously administered) 
finr iwneraal symptoms. She had been att^ked with sore throat; 
«diich became Krorse as the mercury was eontuiued^ and it had 
been tberefose laid aside. On examinatioQ^I perceived asloug^iiog 
iileer, which iiad destroyed -the* uvula, and a good deal of the 
ioft palate. Topical and general Uood-lettiog, and powerful 
esoharoticsy including whi^ butter of aptimony and creosote^ 
iwre u»d io vain. Mqiw^ having di«ffeed with, and •kn«Mt 
oaused the disease, I wns apprdiensive of having recourse to 
% particularly as mercurial fumigation failed. As a last re* 
(NWpe 1 tpe^ted the woman with 4:alomel and opium, adminis^ 
tared in the way I have mentioned. In about thirty-six hours 
abe was in a smart salivation, and the uIcot granulating / she 
iloit her bifggard appearance ; and even within a day at two 
looked ;rud<^ and healthy^ I thought, *' if little was good^ more 
AM betteri** and oeutinued the mercury night and morning. In 
a. few days^ however^ she oomplaiued of vertigo and nervous 
symptom^ lost appetite, and looked ilL The mercury was at 
Auoe laid aside, the morbid symptom^subsided, and Ae left the 
bpspital in about a fortnight, quite well^ with the ulcer in the 
palate healed, and the clef^ .cfiused by the lo» of substance, 
Beady filled up. 

When a treatment of this kind causes only a temporary disr 
•ppeaaanee of the i^ymptoms, it ren^ins a question, whether, on 
their recurrence, mercury should be used in the common way^ 
4» in that whidi has already proved successful ? There aos, 
doubtless, constitutions which oan bear better, and cases which 

VOL. XII. NO. 35. 2 E 



210 Dr. Lendrick on the Use and Abuse ofMereury* 

profit more, by these inercarial *' shocks/' than by ** a course." 
The practice of Mr. Wallace m such cases is very judicioii& He 
administers the bydriodate of potash on the subsidence of the 
mercurial action ; and sometimes thus efiects a cure. On ottier 
occasions it is necessary to give another mercurial diock« Many^ 
previously intractable cases, are cured by thus aUemating thd 
use of bydriodate of potash^ with what I term (from its mariced 
effect in iritis,) the iritic administration of mercury. 

There are indeed some cases of iritis which beautifully illo8« 
trate both the morbid and the salutary action of mercury. Thus 
iritis breaks out under a m^curial course, and becomes aggra* 
vated, as the medicine is continued. Mercury is laid aside, and 
the case is treated by local blood-letting, belladonna, and the in* 
temal administration of turpentine : the symptoms subside ; the 
eye, however^ remains liable to attacks of inflammation ; and one 
of these, more serious than the rest, is cured^ along widi the 
whole disease^ by — mercnry. This is a very important and 
instructive illustration, and shews, both that a disease which ge« 
nerally requires mercury moYheprodticed^ by it in predisposed 
parts, and that sudi may be finally cured by it, if used at the 
proper time. 

We are often embarrassed, during a mercurial course, to de* 
termine whether we are giving too little mercury, or whether 
mercury is disagreeing, especially if its salivary action be but 
slight, the doses moderate, and the case one (such as that of 
nodes) which often yidds to the full, and not to die slight action 
of mercury. This is a matter of the last practical importance, 
as if we give more mercury on the former supposition, when it is 
actually disagreeing with the system, we may ruin the patient I 
think the following considerations will often prove our guide :-— 

1st If the disease has remained /rom the commencemerU of 
the mercurial course unchecked^ the former supposition is, under 
the above circumfttanoes, probably correct, and mercury may be 
cautiously increased.' 

* Mercury may oitMe at well at cure drcptjf» 



Dr. Lendrick on the U$e and Abtise of Mercury. 211 

Qndhf. If the disease fuu been checked and is staUonary, the 
case Is doobtinl. If the mercury be now suspended^ and has 
been ^feyiously inmfficieni, the disease will then gain ground, 
and the indication for a fresh and more abundant administration 
aflbrded. 

Srdly. If the disease has been checked and is now getting 
tOQree, mercury is disagreeing, and it ought to be dUconttnued^ 
at least temporarily; for if mercury once acts on the disease, it 
wilij so long as its action is fkvourable, at least suspend it If 
we have first an amendment y (see No. I.) and then a deterioration 
before mercury b discontinued, we shall lose instead of gaining 
by continuing, and afordorif by increasing it 

Perhaps the day xa&f yet come when practical principles, 
such as those that experience has forced upon us with respect 
toSmercury in the venereal disease, may enable us to use this 
powerful remedy far more extensively, in many more diseases, 
and with much greater success than at present, and on this sub* 
ject I may perhaps (Gh>d willing) again submit my views. 

To Mr. Carmichael a debt of obligation is due by tfie pro« 
fession and the afflicted, for the improvements he has introduced 
into die treatment of syphilis, and for rules of prognosis and 
diagnosis, which prove unquestionably correct in a considerable 
firoportion of cases. Still I cannot subscribe to tlie opinion, 
that we. have data, in the present state of our knowledge of the 
.venereal disease, to prognosticate the result after secondary 
symptoms appear. On the contrary, I think the phrase '* all 
Bt sea" as then a]^icable. So much depends on idiosyncrasy, 
and the chance of an unludiy hit with mercury, either by our- 
eelves or others, (for mercury will be indispensable at some pe- 
riod,) that even the most flattering cases often turn out de^ 

ploraUy. 

For this reason the prevention of the venereal disease 
is a subject of the last importance, and this name is, I think, 
assignable to &e cure of the primary symptoms; for till both 
praetkioners and patients can be got, as formerly^ to look 



313 Pn hMivMi OH theU^e arid Jtbme iffMenk^: 

on these «ymptdtf» ab almdat aothmg oo Iheir bwh aMNinty 
and alqaoftt ejery thing on aocoaot of thdir probiUe coim^ 
quences — &n efficient practicSd oaH scarcely be hoped for wbera 
the apparent danger ift so dig^t. M^ own ebdervatibn of se- 
condary symptoms^ not only establishes a conyiction.of theic 
highly formidable nature, but ateo that tb^ take place in a 
considerably greater proportion of cflae% than is generally wp* 
posed. 

I have long unoe urged on aiy ckMis, in the case ciev^Vf 

doubtful sore <hi ther genitals^ to adopt silch locd aitfl constitii* 

tional tre^ttnent, during tb6 first ^eek from their appeaianoe, m 

will enable them during the ieoond, in case such has hot cam* 

pkteiy disappeared^ to haye recourse to a full course of m^^ry. 

i<'or the mode of conducting this, and the precaMtioos to be 

adopted^ I refer the reader to the aUe works of Drs. CoUes and 

Wallace. Hiere are many other treatises highly vahiable^ be* 

«des such as I have just quoted — Sir A. Cooper's lecturea^ 

and the works of Bacot, Abemethyy MaUuas, Howard, ftc^ 

and though last not least John Hunter. If the latter seem 

tedious in the perusal, let the reader bear in mind the comment 

tator's words, " whenever he has an itUricate case in hii own 

practice he will not accuse Mr. Hunter otprolix&y" 

I do not mean to say that tbfe treatment of the p r bma y 
symptoms in their ftrst stage, by means of mercury iiiUy and efll^ 
oiently administered in the most favourable manner practicable^ 
(for this is the sine qttd non,) might not in many cases, audi as I 
have mentioned, be dispensed with, and yet secondary symptoms 
not appear : but were this the case, even in nine cases out a£ 
ten, (and this is very far from the truth,) the chance of one te 
nine in favour of their occurrence, and the uncertainty as to what 
they may prove if they do occur, is, in my opinion, decimve as 
to a preference for the best mode of treatmrat, whale treatment 
is in our power. 

It was an old opinion that mercury was " carried off" by 
salivation. It is needless to discuss the correotoess of the ex- 



Dc LendriidL on the Use q(Ut 4buee itf Mercury. 21d 

preaabn^ but it is undoubtedly ttud, that a certain action on the 
secretions is mdispenaable for ila salutary operation. In doubt- 
ful cases we find that by acting on tbe skin by means of the 
warm batb^ antimonials, or sacsaparillai or by producing eracna* 
tioDs by purgatives or blood-letting, we secure the fevouraUe 
operation of mercury* An opposite mode of treatment succeeds, 
when mercury is disposed to act too well, and to salivate too 
quickly. Here we expose the patient to a cool air, and admi^ 
nister opiates. 

The morbid action of mercury is alwaya a greater cae than 
what is requisite to produce its healthy or salivary influence in 
the present state of the patient's constitution (if such be practi- 
cable at the time). The salivary action is tbe saturaUon oS the 
constitution, and ptyatism is absent or deficient wfaeo the mer- 
curial action is (morbidly) above, as well as when it is below 
far. The former is shewn by the effect of diminishing it, by 
lessening tbe doses, or increasing the interval between tfaenl. In 
this way we succeed In affecting the mouth, where large doses 
bad previously failed, or caused the morbid action of the remedy* 
Dr. Colles justly remarks, that the very persons who are at one 
time too readily salivated, are at another difficult to affect with 
ordinary doses. The truth is, the terra ^ resistance to mercury "* 
is quite incorrect In most cases too quick salivation, and the 
non-occurrence of salivation, arise from the same cause— ^#00 
great susceptibility to mercury. In the former, the salivary ef-* 
feet takes place soon and obviously, and the mercury is laid 
aside ; in the latter, it takes place soon, but gradually and im^ 
perceptibly— tbe mercury is continued, the proper grade of its 
action is passed through^ the italivary tendency is lost, and the 
more mercury the worde« This latter practice arises frooi the 
supposition, that the ^* resistance" is similar to that whereby aome 
constitutions resist the action of purgatives, and which is over* 
come by increasing the doses. The fiict, that this resistaaca ia 
overcome by diminishing the mercurial action, establisbes thmr 
opposite nature. The object is still belter attained by cGm<» 



214 Dr. Lendrick on the Use and Abuse of Mercury. 

bining with the dmunished administration of mercury, the seere- 
tory treatment mentioned above. Thus the mercurial action 
fcJis back to the healdiy standard. Authors prescribe doses^ 
practitioners must look to efiects. Idiosyncrasy, a temporary 
state of the constitutioui or the result of previous mercurial 
treatment^ may make it more diflScult to adjust grains, than it 
formerly was to manage dradims. If we look back to those 
vexatious cases where Inercury has disagreed, and yet where 
nothing else would cure, we often find a period when a tendency 
to its healthy action displayed itself. Unfortunately the prac- 
titioner, forgetting individual peculiarity in general analogy and 
prescribed doses, considera such an occurrence as encouragement 
to continue the mercury, whidi soon loses its effect I am certain 
that if m many such cases mercury were discontinued on this 
tmidency being observed, and the secretory treatment were re- 
sorted to, the favourable action of the remedy would be brought 
about, and might be continued if necessary. 

Ptyalism subsides in the average of constitutions in about 
eight days, if mercury be not continued. Its continuance is re- 
sorted to principally to keep up the action. Salivation certainly 
seems to be not only the test of its healthy action, but also a 
kind of safety-valve^ since we find that similar effects are pro- 
duced on the disease, without any very marked difference in the 
state of the mouth, by very difllerent doses of mercury, after 
ptyalism is once established. To this remark there are, how- 
ever, exceptions. Sometimes a very slight increase of the dose, 
or a diminution of the secretions by cold, or even a continuance ot 
mercury for die present under the most &voureble circumstances 
of salivation, &c. will cause sudi locator constitutional symptoms, 
as draote that the excessive or morbid action is commencing. If 
mercury be at once stopped, no harm has been done, except that 
its orer-administration has prolonged the period of cure by a 
few days. If it be persi^ed in, the consequences may be deplo- 
rable indeed, in proportion to the state of the patient's constitu- 
tion^ and the previous accumulation of mercury in it I Gael 



Mr. Badford on Inversion of the Uterus. 215 

convinced, that there is scarcely a case of unsubdued syphilis 
where meroory has been freely used, that it has not been 
pushed too ftr at some period. Ground thus lost, is difficult 
to regain. 



Art. XI. — Remarks on Inversion of the Uterus. By Thomas 
Radford, Surgeon Extraordinary to the Manchester Lying- 
in Hospital, &c., and Lecturer on Midwifery at the Royal 
School of Medicine and Surgery. 

{Continued from JVb. XXXIV. p. 25.) 

The opinions of writers and teachers are so discrepant upon the 
practice which ought to be adopted in cases of inversion, where 
the placenta still adheres to the uterus, that it appears impor- 
tant to the writer to inquire into their validity. When we find 
modem writers of the highest authority ranking hemorrhage in 
these cases,* as always dangerous, and sometimes fatal, we 
ought to have strong grounds before we contradict those state- 
ments : but authority, however eminent, ought, and must yield 
to that opinion which is founded upon facts. The frequent ab- 
sence of hemorrhage in this accident is a truth so certain, that 
the writer is astonished that any practice should have been based 
upon the idea of the universality of its occurrence : he alludes 
to the practice of not detaching the placenta, before reversion 
of the uterus is effected. In speaking of the absence of hemor- 
rhage, the writer wishes it to be understood, that he alludes only 
to those cases which have been well managed. It would be 
folly to deny that bleeding may be produced m inversion, as in 



* Denmao, Waller's Edition ; and Francis, American £d. Boms' 8th Edit, 
and also James, Do. Ramsbotham, Practical Observations. Newnham's Essay. 
Ingleby, Obstetric Medicine. Gardien Trait6 complet D'Acconchemens, &c* 
tome iii« p. 309. Boivin and Duges Traits pratiqne des Maladies de TU terns, 
&c. tome i. p. 289 ; and also Heming's Trans, p. 1 19. Sir C. M. Clarke, Ob- 
serrations on those Diseases of Females, &c. p. 161. 



216 Mr. Radford on Inversion of the Vt&nti. 

Other case9> by injudiciom tneatment. Th^ fumour ie Afur aeei<i 
dimt baa been mistaken^ and tfie placenta breagbt away in parif, 
leaving a por^n attached to the fiindas ;* ikte utenta baa been 
forcibly pulled at^f lacerated^^ cut into^g and even 4om Bmtif 
with the crotchetll In such cases it is no wonder that hemorr 
rhage is a prominent feature. 

When considerable flooding occurs during labour^ it always 
depends upon a partial or complete separation of the placenta ; 
but in inversion we find, generally, that the placenta is adherent. 
There are exceptions to this found in the published cases, but 
some of these are not to be dependf»d upon. 

In all cases hemorrhage is more, violent, when the placenta 
is partially detached, than when it is completely separated ; and 
nothing increases it so much as partially detaching, and break- 
ing into the structure of this organ. The placenta, whilst adhe- 
rent to the uterus, is in free vascular communication with it,,and 
if a partial separation &nd disruption be effected, bleeding 
niouths are exposed. But if the placenta be completely detached 
(rom the uterus, this organ contracts as under ordinary circum- 
stances, and the bleeding ceases. The validity of this opiuion 
is shown on reference to those cases where the placenta was re- 
moved previously to reverting the uterus. In many cases in 
which hemorrhage is stated to have occurred, there is great 
reason to suspect that the reports have been exaggerated from 
alarm ; and in many of these cases the accounts are second-hand. 
After natural labour there is a greater or less lochial discharge;i 
some part of which may be concealed from. observation, remain- 
ii\g in the cavity of the uterus ; but in inversion it is otherwise^ 
for the whole of the discharge must pass externally.' In five of 
the cases connected with this paper no hemorrhage took place, 

* BrowQ, Annals of Med. vol. ii. p. 278. Iogleby» Facti and Cases in Obst. 
Medicine, Case p. 228. 

t Cawley, London Med. Journal, vol. vi. p. 278. Hamilton, Med. Comment, 
vd. xvi. p. 317. Clegboro, Case, Med. Comment vol. ii. p. 229. 

X BarUiolinus, Burns' Note, Stb Ed. p. 622. 

$ Ruysch, Obs. 26. H Journal de Med. Bums' Note, p. 621. 



Mr. Radford on Invernon of the Uieruf. 217 

and in the sixths after the birth of the child, '^ a discharge of 
blood now occurred^ but it was considerably less than what hap- 
pened in two of her former labours." In numerous cases on 
record the sanguineous discharge is stated, most distinctly, to 
have been trifling.* In others hemorrhage is not even alluded 
to as an immediate effecf ; a strong presumption, that an occur- 
rence which always claims the active energies of the practitioner, 
could not have exi&ted.f We find in Dr. Hamilton's observa- 
tions on his case, that he decidedly states that hemorrhage did 
not take place, and also that he had seen five cases in which 
this symptom was altogether absent. ;{: 

As corroborative of the writer's view, it may be well to state, 
that in many of those instances, in which it is mentioned that 
hemorrhage was present, there is the strongest ground to infer 
that it was not alarming,§ although in some cases, rude treat- 
ment of the uterus or placenta had been adopted. In the case 
related by Mr« C; White, the discharge could not be serious, 
as the obstetrician, after separating the placenta, and making 
an attempt to reduce the uterus, left the patient, to wait upo» 
that celebrated practitioner, who did not see the case for aK 
hour afterward&ll 

Dr. Davis, in his additional statement to Mr. Newnham's case, 
mentions that the hemorrhage was more than ordinary, and that 
it was observed '^ to gush out from the passage with much force, 

* Brown, Annals of Med. vol. ii. p. 278. Brown, Memoir of Med. Soc. vol. 
V. p. 203. White, Med. Comment., vol. ii. p. 268. Dr. Albers, Annuls of 
Med., vol. V. p. 392. Chapman, Treatise, p. 123. Welsh, Med. and Phys. Jonr., 
vol. V. p. 451. Smith, Ditto, vol. vi. p. 504. Loffler, Ditto, vol. xi« p. 208. 
Hirvie, Pract Directions, p. 21. 

t Cawley, London Med. Jonr., vol. vi. p. 867. Manrioeav, tome ii« p. 559* 
La Motte, p. 496. SmeUie, Case 3rd, Coll. 44. White, Two Cases, p. 435 and 
436. Treatise, &c. Edit. 5. 

% Med. Comment, yol. ivi, p. 316. 

{ Hunter, Annals of Med. vol. iv. Dyson, Mem. Med. Society, vol. vi. 
Clarke* Edin. Med. and 8tirg. Jour. vol. ii. 

I Treatise, &c. p. 431. 

VOL. XII. NO. 35. 2 F 



218 Mr. Radford on Inversion oftlie Vterus. 

and as if the source of it had been mudi nearer to the outtet, 
than what is common on such occasions. The manner of its 
escape resembled the spurting from the vessels of a stump dur- 
ing the relaxation of the tourniquet Jn the operation of amputa- 
tion." From this quotation we might infer^ that the discharge 
was both copious and rapid^ but we are further toM, that 
" about a pint of blood was lost, perhaps something more*** 
Now eVery obstetrician knows that this quantity is often lost in 
common labour. 

Hemorrhage rarely occurs as a primary symptom^ but if 
published cases are consulted, it will be found to happen acci- 
dentally, or in consequence of injudicious treatment and violence. 
In the cases related by early writers on midwifery, we find it 
stated that the accident was frequently fatal^ but at that period 
the practice was in the hands of ignorant mid wives. In the 
present day a different result takes place. 

It has been stated by authors that convulsions frequently 
occur in this accident, but the eases detailed by the writer war- 
rant him in concluding differently. It was long thought that 
wounds of the uterus were assuredly mortal, and that they were 
always accompanied by convulsions. This opinion gave rise to 
the impression, that accidents, or derangements of this organ^ 
would be attended by this formidable symptom. But greater 
experience has proved that convulsions are not essentially an 
accompaniment of wounds of the uterus.t The same unerring 
guide teaches us that convulsion rarely occurs in inversion, un- 
less the womb has sustained some serious injury from violence^ 
and the same result would frequently be produced in organs 
less important than this, if the same mischief was inflicted. 
Those convulsive agitations which are precursory of dissolution, 
are n^ the same with the convulsions referred to in the above 
remarks. 

It has frequently happened that death has suddenly taken 



* Newnham's Essay, p. 35. f See Hall on the C«8veiii Operation. 



Mr. Radford on Inversion of the Uterus. 219 

place, when aetther hemorrbage nor convulmon existed. The 
event is to be ascribed to that dreaciful state of sj^icope which so 
generally attends this accident* This most constant symptom 
depends upon the s^ong sympathy existing between the nervous 
and uterine system; and upon the deficient supply of blood to 
the brain, and other important organs, in consequence of the 
accamulation in the vascular system of the abdomen, and pro* 
duced by the sudden removal of that pressure which all the ab* 
dominal viscera had previously received. The pulse is quick 
and feeble, in consequence of these sudden changes, and it 
is worthy of remark, that it acquires power as soon as the uterus 
is reduced, t 

In this accident, the patient's appearance is such, as to 
lead to the conclusion that she must have lost a large quantity of 
blood ; when, in reality, the quick feeble pulse and deliquium, 
arise from the shock sustained by Uie nervous and vascular sys* 
tems, in consequence of the displacement of so important a viscus, 
which, a short period before, contained the child, placenta, and 
liquor amnii, and occupied so large a proportion of the abdominal 
cavity. Some delicate females do not bear the changes which 
occur in natural labour, without suffering from the effects of 
8yncope4 Practical obstetricians are so well acquainted with 
this circumstance, that position and a regulating bandage are 
constantly adopted to guard against such a result Mr. White 
urged the necessity of not accelerating the passage of the 
8houlders,§ and Dr. Osborne advised the practice of retarding 
the exit of the head in order to prevent these consequences. 
fa ascites, the withdrawal of the water without regard to position 
and abdominal support may induce a fatal syncope. 

Although the fainting which happens in inversion is of so 
serious a nature, yet it is a great satisfaction to know, that if it 

* Vide authon already quoted. f White, Treatise, p. 433. 

X RamsboUiam, FracU Obs. part 1, p. 206. Dr. Davis, Obstetric Medicioe. 

S Treatiae, &c. p. 364. 



220 Mr. Radford on Inversion of the Uterus. 

does not soon prove fatal, there is not much occasion to appre- 
hend danger from its future occurrence. When the first shock 
of this accident is overcome, and the equilibrium of the circu- 
lation restored, other dangers then threaten the unfortunate 
patient 

When the uterus is inverted, only in a slight degree, the 
reduction may be accomplished with great ease, and the at- 
tempt should be made as soon as it is discovered. As the 
fundus uteri has not, or only slightly passed through the os, 
the placenta cannot wholely protrude through this orifice, and^ 
consequently, the fundus should be returned before the placenta 
is separated.* For if an attempt were made to detach the 
placenta, the operation must be slow, uncertain, and incomplete^ 
and the danger of hemorrhage incurred, or a greater degree of 
inversion produced. When the hand is introduced through 
the OS uteri, the fingers should be slightly bent, so as to form a 
kind of crutch, to carry up the fundus, which sometimes rapidly 
springs up.t The placenta is now to be separated, and the 
hand retained until the uterus contracts. In the higher degrees 
of inversion, the uterus in general remains only a short time 
unaffected. The os, irritated by the body protruding through 
it, begins to contract, and soon closely embraces it, and becomes 
ere long rigid and unyielding^ The ilindus soon tumifies in con- 
sequence of its circulation being interrupted, by the constricting 
OS uteri, and likewise from the unfavourable position in which 
it lies ;§ it is not long before this part becomes tender and in* 
flamed.|| 

The OS uteri is more or less irritable in different indivi- 



* See Case 5th of this paper. 

t Gates 3od and 6th of this paper. Merriman, Cases l8t» 2iid. No. 30, 
Appendix. 

t See Case 3rd. White, Med. Comment., p. 250. Dr. Denman, Introd. 
Waller's Ed., p. 420. Dr. Hamilton, Med. Comment., vol. zti. p. 318. 

$ Mauriceao, Obs. Heister, vol. x. p. 1087. Newnham's Easy. Pen 
Pratique des Accouchemens, p. 421. Rnjscb, Obs. 10. C. White, Treatise, 
p. 432. II Case Srd. 



Mr. ]^dferd on Invenion ofihe Vieni9. 221 

duals^ Bsnd consequently does not always become an obstacle to 
reduction equally^ and at the same time.* 

In cases where Ab accident increases in degree after a cer- 
tain time has elapsed ; or where it becomes irreducible^ the pa* 
tient suffering but little pain, which occasionally happens ; theos 
uteri will be found comparativdy soft, and not constricting the 
body in an equal degree. But when the ftindus enlai^es and 
inflames soon after the occurrence, then the os uteri is fbaad 
rigid, and firmly embracing the part 

It is of great practical importance to know that the fundus 
is so frequently found enlarged, and that the os uteri soon con- 
tracts and acquires a rigid character. In one or two hours these 
changes may have taken place. Dr. Dennnn was unable to 
reduce the organ after the lapse of four hours.f When tibe 
OS uteri is found soft and yielding, it is in a state favoundde {br. 
the operation of re-inverting the fundus ;% but if it is rigid, and 
girds the body firmly, the fundus being enlarged and tender^ 
then the reduction will always be difficult if not imp08SiUe.$ 

In the treatment of this accidoit, the great object to be con- 
stantly kept in view, is to attempt the re-inversicm as soon aa 
possible after the occurrence. Bnt in general the placenta 
adheres to the inverted organ, and the question is, whether it 
should be separated or not, before, or after the reduction. It is 
an important point to settle, especially as there is such a di&r-f 
ence of opinion upon the subject. Dr. Denman leaves too JBudi 
to the judgment of the young practitioner. Dr. Boms advisea 
the fundus to be returned^ widi the placenta adhering. Dr. 
Merriman says^ ^in a case of this kind, wbidi occurred in my 
practice, the placenta was removed without prejudice, but I 
think I should not, in future, ranove the attached p lacen t a ^ till 
after the uterus was restored to its right position."!! For why ? 

* Cases 3rd and 6th logleby TracU and Cases, &c, pp. 226, 227. Ptcksa* 
SOD, Med. Gaiette, No. 372. Dr. Belcombe, Ditto, toI. vii. p. 783. 
t IntroductioD, &e. Waller's £d., p. 420. | Case 6^. 

$ Case 3rd. I SynopMs, p. 151. 



222 y^r. Badfotd on liwermn of lie U^u$. 

The dregd of bemonbage is the reMon assigned, why the pla- 
centa should not be first detached, but the writer trusts, tb^t 
the cases.he has adduced, and the references he has made, are 
wiificient eridence to thecontrary. In nocase has this dreaded 
efieet been induced, or eren aggravated by a compUie aqpara- 
tion of the placenta. The uterine vessels are as efleotually oon-* 
strieted under this accident as when the organ is in its natural 
situaticHi, if the {dacenta be entirely detached ; and flooding is 
produced here, in the same manner as in lurdinary cases, by a 
pavtial s^Muration or disruption. As the greatest disadvantage 
arises from failing in our first attempt, it is the more necessary 
that every impediment should be removed, so that we can pro- 
ceed with the greatest chance of success. By delay the organ 
beooKies less fit to bear the operation, not only from the in-> 
creased ase of the fundus, and the contraction of the os, but 
also from the incre^ed sensibility, and irritability, which it has 
acqpne^, even previously to its becoming actually inflamed.* 
The altadied placenta must increase the obstade, because the 
fundus cannot be so fredy and suflSciently compressed. The 
nsiikof free manipulation w<nild lead to partial detachment and 
disD^^n, and eonsequratly to floodmg. 

By detaching the placenta great advantages are gained ; the 
bulk of the part is diminirfied, the operator is enabled further 
to «eduee the sise of the fundus itself by compression ; and he 
has move freedom to judge of the changes he has eflkcted. K 
Hisse admoitages are demed and the plan be olyected to, what 
method nrast ibe adapted, in case we should &il in our endea* 
vmirs to ndnoe ^ uterus whilst the placenta still adheres to 
it ? Sureljr no obstetrician would, in such a case, think of 
kaviog his patient in that state, until the plaoenta was detached 
by flie> effiniii of nature. 

But if he Iben determined to remove this mass, he would 
have to run flie risk of this dreaded hemorrhage, not lessened 

* Sse Cue 3rd. Hunter, White, Windsor. 



Mr. Radford on InMrrion oftke IKffrus. Ti23 

t>y fats interference. When the placenta is detached, t>lir next 
object should be, to attempt the reduction of the general bulk 
of the tumour by compressing it* We are indebted to Mr. 
C. White for this method* The {dan recommended by sMie 
writersyf to push the fundus directly upwtUnds should not be 
adopted. There are strong reasons to think that the fimdus^ is, 
after, the os uteri, the most irritable part of this orgim. When 
die accident has existed a short time, pressive upon this portion 
induces pain, bearing down, and hemorrhage, but the body may 
be taken hold of and compressed4 If we could press .the fim- 
dus upwards, and thereby dimple it vnthin itsdf, we shoidd 
find ourselves opposed by a double inflexion, for the body would 
be grasped by the os uteri, and the fundus would be within ilto 
body. It is obvious that our force should be directed so ae to 
act upon the angle of inflexion, or where it turns into itself. The 
I^an to be further adopted is stated in the cases related in dits 
paper. Every means diould be used to insure the faU oontrac- 
tion of the uterus after reduetion, and writers dwell upon tiiis 
point because a second accident has happened. 

Dr. Denman's want of success, in not having been able to 
re-invert the uterus, after it had bera down four hours, has tended 
to paralyse the Clergies of the obstetrician when he has been 
called to the case at a late period* If the immediate eflfects of 
the shock sustained in this accident are oversone, and the organ 
remains unreduced, either from inability or want of determina- 
tion on the part of the praotitmner^ a number of inconveniences 
wad dai^ers are to be expected. On account of the dependent 
pootion of die tumour bandages and supports are always re* 
quired, and the active exertions of the patient are gready im-* 
peded. It falls down upon the dightest straining, and inflaenctes 
the functions of the adjacent organs. The uterus itself is liable 
to inflammation^ ulceration, and gangrene, life is miserable, and 



* See Cue 4th, t Bums. t Hnnter't Annftlf of Med, vol. it. p. 208. 



1 



224 Mr. Smith on certain Infuries tiftht 

the patient, sooner or later, &IIs a sacrtfioe to the mt»6-piimlent 
and sanguineous dischai^ges. 

These circumstances, with others, rehtting to the married 
state, demand and justify the removal of die uterus when 
irreducible. But it is the opinion of the writer, that this 
operation, as before stated, will not be often required, if a 
proper view is taken of the circumstances which impede tfie 
reduction. The energies of the obstetrician should not give 
way, if unsuccessful in his first trial, but he should repeat the 
attempt When the inflammatory symptoms come on, they are 
to be combated by active remedies, and when subdued further 
exertions should be made to re- invert the organ.* In some of 
the oases which are detailed in periodicals, we find no attempt 
made after the first has failed. The inverted womb has, how- 
ever, been re-inverted after a considerable length of time,— of six 
or seven hours,t of seventeen hours,} of twenty-four hours,^ of 
three days,|| of twenty-seven hours,1[ of seven days,** of eight 
days, ft and in one case after it had existed twelve weeks.}} 



Art. XII. — Remark9 vpon certain Injuries of the upper 
Extremity of the Humerus. By Robert W. SMrni, 
A.M.,M.R.I.A., Lecturer on Surgery at the Richmond 
Hospital School of Medicine, &c. &c. 

When we consider the varied and extensive motions of the 
shoulder joint, and their importance in the daily occupations 
of life : when we reflect upon the liability of this articulation to 
accidents, and the diflSculties which sometimes present them- 
selves to the surgeon, when he is seeking to distinguish between 

the luxations and the fractures of its bones, and upon the stiU 

■ _ * 

* SeeCfttedfd. t Loffler'iCtte. t WfaHe'i Caie. 

I Mr. Wyoter't Cats* | Mr. Cawley'i Cim. f Mr. DicktaMn'* Cue. 

•• Cue 6th. ft Mr. Ingleby't Case. XX Dr. Belcombe'f Case. 



Upper Extremity of the Humerus. 225 

more embarrassing nature of the case when these tv?o lesions 
co-exist^ we must at once see and admit the necessity of inves- 
tigating with the utmost patience^ a class of injuries^ which, if 
neglected or misunderstood, entail great misery upon the pa- 
tient Much, certainly, has been done already to clear away 
our doubts upon these injuries by Beyer, Sir A. Cooper, Du- 
puytren, Malgaigne, and others, but something still remains to 
be accomplished, for in every hospital, cases are frequently 
seen, which almost defy the ingenuity and discernment of the 
experienced surgeon to explain, and the true nature of which, 
dissection has not yet revealed. Dupuy tren himself has said, and 
said truly, that all solutions of continuity of bones, in the neigh- 
bourhood of joints, are the sources of numerous errors. It is 
to the rarer and more obscure injuries of the bones of the shoul- 
der joint, tliat I wish to draw attention, and trust that I shall be 
able in the following observations to remove some of die doubts 
and uncertainties by which they are enveloped. 

Case I. — ^In July, 1834, 1 was called upon to examine the 
body of Julia Darby, set. 80, who had died of chronic pulmo- 
nary disease. Upon entering the room, the appearances of the 
left shoulder joint at once attracted my attention, and struck me 
as being different from those which attend the more common 
injuries of the joint. The shpulder had lost, to a certain extent, 
its natural rounded form ; the acromion process, though unna* 
turally prominent, did not project as much as in any of the lux- 
ations of the head of the humerus. The breadth of the joint 
was doubled; upon pressing beneath the acromion, I could 
plainly distinguish a portion of the head of the bone occupying 
the inner point of the glenoid cavity ; it formed a tumour, per- 
ceptible through the sofl parts, while the remainder, and by far 
the larger portion of the head of the bone, lay beneath the level, 
and internal to the coracoid process ; and between these two por- 
tions, the finger sunk into a deep depression or sulcus, placed 
immediately below the coracoid process. The elbow could be 
brought into contact with the side, and there was no appreciable 

VOL. XII. NO. 35. 2 G 



336 Mr. Smifb on certain Injuries cfihe 

change in the length of the arm. Such were the external cha- 
racters of the injury, and from these alone I was unable to pro- 
nounce positively as to its exact nature, but conjectured that it 
was some variety of the luxation forwards. Upon removing 
the sod parts, the head of the bone presented itself, increased to 
nearly double its natural breadth ; it ky beneath, and internal 
to the coracoid process.* The greater tubercle was completely- 
broken off from the shaft of the humerus, and in situation cor- 
responded to the inner part of the glenoid cavity ; the fracture 
traversed the bicipital groove, which, in consequence of the 
displacement which the head of the bone had suffered, was si- 
tuated exactly below the coracoid process ; the glenoid cavity 
was changed both in form and size, it was smaller than natural, 
nearly flat, and broader above than below. A new, shallow 
socket was formed for the head of the bone, upon the axillary 
mar^n of the scapula, and bony matter was deposited in the 
capsule, which was greatly enlarged ; the cartilage had been 
nearly altogether removed from tlie head of the bone, which 
was covered by an ivory deposit. The injury was evidently of 
very long duration, but of the exact time and mode of its occur- 
rence I could obtain no precise information. 

In November, 1833, a lecture was delivered by Mr. Guthrie, 
OB a peculiar injury of the shoulder joint ; this lecture (which 
was published in the London Medical and Surgical Journal, 
and also in the Lancet) I had not read, when the case above 
detailed came under my observation. But the appearances of 
the injury in the cases detailed by Mr. Guthrie, are so very simi- 
lar to those now described, that I am pretty sure the lesion 
was also similar. The first case mentioned by Mr. Guthrie, is 
Aat of Louisa Chapman, set. 1 1 ; she had fallen upon the 
shoulder ; a considerable prominence was noticed upon the in- 
ner of the anterior portion of the joint, a prominence liable to 
■ -- ■ ■ . . _ - ■ ■ * 

• See pitie. 



t 



Vpper Extremity of the Hamerm. 227 

be mistaken for the displaced head of the bone, were it not that 
the whole of it did not project internally^ but on the contrary, 
the greater part could be felt in the glenoid cavity. 

" If," says Mr. Guthrie, '• the thumb or fore-finger of the 
led hand be placed upon the internal protuberance of bone, whilst 
the elbow is rotated by the right, the protuberant portion of the 
humerus is found to obey the motion given to the elbow, in the 
clearest possible manner. If the fore*finger be carried outwarcb 
and placed upon that part of the. joint in which the external 
part of the head of the humerus ought to be placed in its nor- 
mal state, it will be found there, and moving most distinctly 
under the finger when the elbow is rotated ; the arm can be 
elevated and the hand placed on the top of the head ; there is 
no peculiar or decisive sensation communicated to the finger 
when pressed into the axilla, and the elbow can be pressed close 
to the side, although it tends a little backwards ; if the point of 
the fore-finger be placed immediately below the middle of the 
acromion process, it sinks into a hollow between the protuberant 
point of bone, and the articulating part of the humerus which 
moves in the glenoid cavity, and if the two shoulders are com- 
pared, the greater breadth of the injured one is apparent 
What is the nature of the injury ? dissection has not explained it, 
but I believe that it is a longitudinal split of the humerus; the 
accident always happens in consequence of a fall on the point of 
the shoulder, in which the head of the humerus first meets the 
ground, and receives the shook. I believe the split separates 
the small tuberosity, with more or less of the head, and extends 
in the direction of the bicipital groove, and I suspect that the 
tendon of the pectoralis major in front, and those of the latissi- 
mus dorsi and teres major behind, prevent displacement by act** 
ing in the manner of a hinge." Mr. Guthrie adduces three 
other instances of the accident, in all of which the symptoms 
were nearly alike ; in the third case, which is that of Colonel 
Yorke, who fell from his horse, on his left shoulder, the only 
symptoms diflfering from those in the case of Chapman, were a 



228 Mr. Smith on certain Injuries of the 

little more protuberance on the inside, and a crepitus on rota- 
ting the elbow. The fourth ease is that of a gentleman, aged 
eighteen, who fell upon the poiht of the shoulder, and was sup- 
posed to have dislocated the head of the humerus ; the bone, 
when reduced, did not, however, remain in its situation. A 
the end of three weeks, Mr. Guthrie first saw the patient; he 
found that the elbow was carried very far backwards, and the 
head of the os humeri proportionably forwards, and apparently 
dislocated in that position, but the prominence was not round, 
like that of the head of the bone, and did not give that sen- 
sation to the touch ; on the contrary it felt as if the head 
of the bone was split as well as dislocated. In the at- 
tempts which were afterwards made to reduce the bone, 
the prominence could not be entirely removed ; the outer por- 
tion of the bead of the humerus appeared to be in the glenoid 
cavity, but the greater part of it was internal to it. In this case 
Mr. Guthrie supposes that the capsular ligament of the joint 
must have been torn, and the whole head of the bone dislocated 
as well as split, which might be a reason why it so readily be- 
came displaced a second, and even a third time. 

Before making any observations upon these cases, or upon 
that, the dissection of which came under my own notice, I shall 
detail the particulars of one or two other cases which were lately 
admitted into the Richmond Hospital. . 

Case II. — John Morgan, «t. 62, on the 1st of January, 
1836, while running smartly tripped over a stone, and fell with 
violence upon the left shoulder. When the man was admitted 
into hospital, which was several months after the occurrence 
of the accident, the injured limb presented the following ap- 
pearances : the acromion was unnaturally prominent, but the fin- 
ger could not be suqk into the glenoid cavity, at the inner part 
of which, beneath the coracoid process, a larger, prominent, bony 
tumour could be felt ; and externally, beneath the acromion, a 
second osseous prominence was perceptible even to the eye ; 
these two projections were separated by a deep and distinct ver- 
tical depression^ corresponding to the line of the bicipital groove ; 



Upper ExtremUy of the Hwmerui. . 229 

there was no appreciable alteration in the length of the arm, or 
in the depth of the anterior wall of the axilla ; the breadth of 
thd joint was nearly double that of the opposite one^ the head of 
the bone was changed in form^ and irregular, and the direction 
of the axis of the humerus altered ; the muscles upon the dor* 
sum of the scapula were wasted, the arm was powerless, the 
elbow stiflT, and the wrists and fingers permanently extended ; 
the scapula moved with the arm. The opinion which I formed 
of the case was, that there had been a fracture, which traversing 
the upper part of the bicipital groove had detached the greater 
tubercle of the humerus, and that, as a consequence, the head 
of the bone was slightly displaced forwards ; this was also the 
opinion of Mr. Adams, under whose care the patient Was placed. 
As the man still lives any opinion upon the case must, of course, 
be cautiously received ; although from the resemblance which 
the symptoms bear to those noticed in the case of Darby, there 
is every probability that the nature of the injury was similar in 
the two cases. 

Case III. —A man aged about 30 years, fell from a house 
three stories high, and received a severe injury of the left should 
der joint. Upon his being conveyed to the Richmond Hospital, 
the pupil in attendance, finding the head of the bone placed 
more forwards than natural, the acromion process more promi- 
nent, the deltoid muscle, to a certain degree flattened, the 
elbow separated from the side, and all motion painful, especially 
rotation outwards, while the hand was in a state of pronation, 
conceived that the case was one of dislocation of the head of 
the humerus forwards, under the pectoral muscle. The mode 
of reduction by the knee in the axilla was had recourse to, and 
the arm was bandaged to the side. However, after a short time^ 
the patient not having experienced any relief, the bandage was 
removed, when it was found that the joint presented exactly the 
the same appearance as at first ; and, upon more close examina- 
tion, a crepitus was distinctly heard ; this circumstance, along 
with the recurrence of the deformity, led to the idea that the case 
was one of fracture of the neck of the scapula. However, when 



330 Mr. Soiith on cetiain If^uries cfjthe 

Uie patient wns visUed hj Mr. Adaas, the power of diagnom, 
witb^ifbich this intelligent surgeon isgifted^atonee enabled him 
to form a more correct opinion, and he expreoied hts' belief^ 
diet there was neither luxation of the humerus, nor injury of the 
scapula. I saw the patient along with Mr. Adams, and ftiUf 
concurred with hhn, as to the nature of the ii^jury. The ap- 
pearances, which the joint presented were similar to those no^ 
tieed in the cases of Oarby- and Morgan : these were briefly as 
fi>Uows: the acromion was more prominent titan natural, hot 
still the finger could not be sunk into the glenoid carity ; the 
arm was separated (rem the side, but could be easily approxi'^ 
mated to it ; the breadth of the joint was nearly dooble that of 
the opposite one, and two tumours were distinctly noticed, the 
inner one the larger of the two, and placed under the coracoid 
process, was evidently constituted by the head of the humerus ; 
¥4iile the external and smaller was apparently formed by the 
greater tuberosity, and the two were separated by a deep and well 
marked sulcus, corresponding to the line of the bicipital groove; 
I conceive then, that in this case, the injury was a fracture, pass- 
ing through the upper part of the bicipital groove and detaching 
the greater tubercle from the shafts ot* the bone. 

I do not see how the appearances are to be explained upon 
aoay other supposition; it could not have been a fracture of the 
neck of the scapula, for in this case the ana is lengthened, and 
the deformity is readily removed by pushing the elbow up« 
wards, but re-appears when the limb is unsupported ; whereas in 
the case under consideration, there was no lengthening of the 
arm, on the contrary, it was slightly shortened, nor could the 
d^rmity be completely removed by any means whatever. At 
first sight, the appearances of the joint, no doubt, resembled 
those of dislocation forwards, but, the facility of approximating 
the arm to the side, and the great increase in the breadth of the 
joint, affarded ready marks of distinction. Ncyw, if we com- 
pare the appearances in the instances whish I have detailed with 
those described in Mr. Guthrie's cases, it must be apparent. 



upper Exiremiiy qfihe Humerus. 231 

that the nature of the injury was similar Hi all^ and, by a refe- 
rence to the post mortem examination, in the case of Darby, I 
think it must be allowed, that although Mr. Guthrie^s conjecture 
approximated closely to the truth, he has not exactly made out 
the nature of the lesion* The situation of the fracture may not 
be, and most probably is not, tbe same in all cases, yet some 
part of the greater tubercle is, in my opinion, in ef ery instance 
its seat, and not the lesser tubercle, with more or less of the head 
of the bone, as supposed by Mr. Guthrie. I have nerer ascer- 
tained by post mortem examination, that the fraeture es^nded 
vertically, or obliquely, so far down the shaft of tbe bone, as to 
be influenced by the muscles which ccHistitute the folds of Ae 
aodlla, nor, even though it did do so, can I clearly understand, 
how, as Mr. Guthrie supposes, the tendons of these mnscles 
could act io the manner of a hinge, so as to prevent displace- 
ment. What occurs in the eases under consideration, is, in my 
opinion, simply this, — a fracture traversing the upper part of the 
bicipital groove, detaches the greater tuberde of die humerus, 
thus annulling tbe action upon the humerus of the supra-spinatus, 
infra spinatus, and teres minor ; ihe folds of the axilla, the sub- 
^capularis and tbe anterior portion of the deltoid, then act almost 
wiopposed, and draw the head of the bone forcibly inwards 
Ugainst the inner part of die capsular ligament, and if, at the 
sftitte time, the inner border of the glenoid cavity be broken, 
(which, I suspect, is by no means a rare occurrence,) the head 
of the bone passes still further inwards and beneath the cora- 
coid process, amounting, at length, to an actual displacement, 
which is- permitted by the increased sise of the joint, just as a 
displacement of the head of the fennir will often be the coose* 
lyaence of a fimctare of tbe acetabulum. 

In the fourtli case, detailed by Mr. Guthrie, that of a gen- 
tfemaB, ast 1ft; it was aipposed that tfie heed of tbe bone was 
dnkicttted as wdl as split ; it became displaced a seoond, and 
evoi a third time» afttf having been reduced; and Mr. Guthrie 
supposes that the capsular ligameat imut have been torn, and 



232 Mr. Smith on certain Injuries of the 

the whole head of the humerus dislocated ; I think it is more 
probable^ that^ In this instance, the glenoid cavity was broken 
and the greater tubercle detached ; for, in the cases under con- 
sideration, the injury is always the result of vicrfence, applied 
directly to the shoulder joint, and, under such circumstances, we 
know that fracture is to be expected, rather than luxation, which 
will much more' probably occur, when the violence is applied 
at a distance from the shoulder, as when a person, in falling, . 
alights upon the elbow. The facility with which the displace- 
ment re-appears, after reduction, is also upon this supposition 
readily accounted for ; just as in a case which came under my 
observation some time since, in which the neck of the femur be- 
came a second and a third time displaced, in consequence of 
a fracture of the acetabulum. 

The symptoms of the injury which I have been attempting 
to describe, and the degree of displacement which the heed of 
the humerus suffers, must vary considerably, according as the 
fracture has separated more or less of the greater tubercle r if a 
small portion only be detached, the abnormal appearances of the 
joint will be but trivial, and, perhaps, the injury will altogether 
escape discovery ; but, if the entire of the process be separated, 
it will give rise to a considerable increase in the breadth of the 
joint, for the inner portion of the bone will be drawn inwards, 
and a deep sulcus will be apparent in the- site of the bicipital 
groove ; and lastly, if along with the fracture of the tubercle^ 
there is a second traversing the inner part of the glenoid cavity, 
there results from this double lesion the greatest degree of dis- 
placement which can occur, without laceration of the capsule and 
actual luxation, and it is in this last case, particularly, that the 
frequent recurrence of the displacement after reduction is so 
remarkable. 

In a case published by Mn Crampton,^ the attachments of 
the tendon of the supra-spinatus and infra- spinatus muscles 

■ 

* Dablin Journal, ?oL iii. 



Upper Extremity of the Httmerus. ^ 233 

were torn off> along with the part of the bone they were insert- 
ed into, and the same circumstance was long ago noticed .in a 
case detailed by Mr. Thompson ;* but both these cases were 
examples of true and complete dislocation, to which it is not 
my object to allude at present 

It does not seem to me very difficult to distingubh fracture 
of the greater tubercle, from luxation of the head of the humerus. 
One of its most remarkable and diagnostic features is the great 
increase in the breadth of the articulation ; moreover, the glenoid 
cavity is not entirely abandoned ; the acromion process is not as 
prominent as in luxation ; the displacement is very readily pro- 
duced ; we cannot depress the deltoid muscle, as in dislocation ; 
and lastly, the violence which produced the lesion has been di- 
rectly applied to the injured part. With respect to the prognosis, 
I conceive that a fracture, analogous to that found in the case of 
Julia Darby, must be exceedingly difficult of cure, most proba- . 
bly ligamentous union is the most we can expect. In this re- 
spect, the injury somewhat resembles fracture of the neck of the 
femur within the capsules ; in the latter case, one great obstacle 
to osseous union is the difficulty of keeping the joint motionless; 
in the former, the same cause, although perhaps operating to a 
less amount, must still, I conceive, to a certain extent interfere 
with the process of union by bone; and again, it is not less diffi- 
cult to keep the fragments in contact, for the head of the bone 
will be drawn inwards by the folds of the axilla, while the tube- 
rosity will move in the contrary direction, obeying the action of 
the muscles inserted into it Thus there is a considerable dis- 
placement, according to the breadth or thickness of the bone ; 
and to this will be added a displacement according to its length, 
if the head of bone be drawn inwards, sufficiently &r to enable 
it to dear the coracoid process ; for it will then be drawn upwards 
by the coraco-brachialis, biceps, and other muscles, whose di- 
rection is nearly parallel to the axis of the humerus. Such, in 



* Med. Obs. and Inq. vol. ii. 
VOL. XU. NO. 35. 2 H 



^ Mr. SmiA on eertain Injuries of the 

fy^ 1¥M the OEiye la the {veparation^ from whicb the occonv- 
panying plate haa been taken^ for the lesser tuberde was placed 
abo?e the greater ; whereas, in the normal oondition of the humer 
rua> tfie reverse is the casej the summit of the greater being 
above that of the lesser tuberosity. 

Before leaving the subject of displacement of the heads of 
bonesj as a consequence of fractures extending into, or in the 
neighbourhood of jointsi I shall detail the particulars of a case 
of fracture of the acetabulum, which I lately had an opportunity 
of seeingi and to which I have already alluded. 

Thomas Venables, set. 25, on the 4th October, 1834, received 
A severe injury of the right hip-joint, in attempting to leap 
across a ditch : while running to the leap he stumbled, in oon- 
jBiOquence of the sofhiess of the ground, and in order to clear th? 
ditch, was obliged to make a very powerful spring ; he alighted 
with great violence upon the right leg, and in a very oblique 
menner, the outer side of the foot and heel sustaining the prinr 
eipi(l shock, which he described to h^ve been terrible. He MX 
ittupediately, and was unable to rise fVom the grounc}, or tp 
^k or stand when raised. Soon after the occurrenpe of the 
ftocident he was seen by Surgeon Hilles, under whom he re;> 
mained for some time, and to whom I am indebted fpr an account 
of the appearances whicb the limb presented immediately after 
the accident When the patient was supported in the ereot 
posture, the appearance of the limb excited at first sight a 
suspicion, that the he^d of the femur was dislocated either upon 
the doreum of the illumi or into the sciatic notch. The limb 
yf€^ shortened about two indies, the heel drawn upwards, Uu^ 
foot was inverted, the knee advanced, and thrown across the 
oj^site one, and a bony tumour was perceptible upon the dor*r 
sum of the ilium ; rotation outwards gave great pain ; the tro« 
chanter was raised nearly to a level with the anterior superior 
qiine of the iliuni, but was one inch further removed from it 
tfian rmtural. No crepitus was discovered. On the following 
morning, an extending force being epplied, the head of the bone 



Upper Extremiy of the Humerui. 23d 

pUMed into its natural situation^ and the defoiteity of the limb 
disappeared ; the botie^ however^ did not pass into its socket 
with the usual and well known noiso ; on the contrary, its gra* 
dual change of position was accompanied by a most unpleasant 
cringing or grating sound, like that produced by the rubbing 
together of the two flragments of a broken bone ; the patient was 
placed in bed, and the limb secured in the nsual manner^ 

Monday, 6th.«^When the patient was visited this morning, 
it was found, that during the night the head of the bone had 
started from the acetabulum, and all the former signs of the injury 
bad re-appeared, and it was observed that, although ttie foot was 
inverted, the patient had the power of everting it to a consi- 
derable degree. This circumstance first gave rise \o the snspi* 
cion, that the injury was not a simple dislocation. On Tuesch^ 
the displacement was a second time reduced ; and the case pro^ 
ceeded fhvourably until Friday night, when, owing to the distur- 
bance produced by a purgative medicine, the dislocation recur- 
red a third time. An accurate examination being now instituted, 
to discover the existence of a fracture, a distinct crepitus was 
perceived at the upper and posterior part of the ac^bulom. 
The cre{Htus, the frequent recurrence of die displacement, and 
the integrity of every portion of the femur, rendered it suffi- 
ciently obvious, diat the brim of the acetabulum was broken ih 
ihe above-mentioned situation. The bone was a third time 
restored to its place, and a strong band passed around the pelvii. 
In 1836 the man was admitted into the Richmond HospHal, 
under the care of Mr. Adams, who had seen the case from ils 
commencement. He was at this time unable to Walk without 
tfie asMstance of crutches. The injured limb was one inch and 
a half diorter dian the other ; when standing, he rested it upon 
the points of the toes, the heel being drawn upwards ; bttt a 
-slight degree of extension was suflBcient to restore it to its natu- 
^ral lemgth i and, indeed, when the man was lying in his bed, 
-diere was scarcely any perceptible difference in die length of 
the two limbs : the breadth of the injured hip was considerably 



236 Mr. Smith on certain Injuries of the 

greater than that of the sound one, and the head of tlie femur 
obviously enjoyed an unnatural extent of motion ; in fact it 
moved in a socket that was much too large for it ; it could be 
pushed upwards, so as to produce a shortening of the limb, to 
the extent before-mentioned, and it always ascended when the 
patient endeavoured to support his weight upon it, and in many 
of the motions of the jomt, the rubbing together of the broken 
surfaces was still distinctly audible ; there did not appear to 
have been any attempt to accomplish osseous union. 

The above case presents us with an example of an accident, 
which is of very rare occurence, and one which, from its liability 
to be misunderstood, and the difficulty which attends its treat- 
ment, is well worthy of attention. What are the cases with 
which it may be confounded ? they are, I conceive, the ordinary 
dislocation upon the dorsum of the ilium, or into the sciatic 
notch; the congenital luxation of the hip, and fracture of the 
neck of the femur with inversion of the foot. In the case which 
I have related, the shortening of the limb, the inversion of the 
foot, and the tumour upon the dorsum of the ilium, were strongly 
calculated to mislead the judgment, but the power which the 
patient possessed of everting the foot and the existence of a cre- 
pitus, sufficiently distinguished the injury from the ordinary 
luxation upon the dorsum of the ilium ; the crepitus, however, 
was not at first perceptible, it was heard for the first time dur- 
ing the attempts at reduction; the rough, grating sound then 
produced was the first circumstance which raised the suspicion 
that the case was not one of simple luxation, but rather of dis- 
placement with fracture, the former the consequence of the 
latter, and the frequent recurrence of the displacement after 
reduction shewed the correctness of this opinion. The injury, 
under consideration, resembles in many respects the congenital 
luxation of the hip. In the latter, as Dupuytren has remarked, 
every time that the person steps, the head of the femur rises 
into the external iliac fossa, and all the symptoms of the dis- 
placement become more evident; because,thehead of the femur 



Upper Extremty of the Humerus, 237 

not beiDg fixed, undergoes a continual displacement, and is 
elevated or depressed, according as it bears or is free from the 
weight of the body. When the person lies down, the symptoms of 
the displacement, in a great degree, disappear, and in this position 
we can shorten or elongate the limb at pleasure by a slight 
extension, or by pressing it upwards; or ifwe grasp the iliac crest 
and great trochanter, it becomes evident that the bone suffers a 
displacement to a variable extent, and by this elongation and 
shortening, the signs of the displacement appear and disappear. 

The same or similar symptoms occur, when, the brim of the 
acetabulum being broken, a partial displacement of the head 
of the femur is produced ; the limb can be shortened or elon- 
gated by extension or by pressing it upwards, and the rising of 
the bone into the iliac fossa always occurs, when the weight of 
the body is thrown upon the injured limb, for the acetabulum is 
increased in size to a degree corresponding to the extent of the 
fracture ; the capsular ligament is powerfully stretched over the 
head of the bone, and in time acquires a great degree of thick- 
ness; in some cases it is torn, and the ligamentum teres, if 
not ruptured, acquires, in all probability, a gradual increase of 
length. 

We see, therefore, that the two cases resemble each other, 
in the circumstances of our being able to elongate or shorten 
the limb by extension or by pressing it upwards, and the ascent 
of the bone when the weight of the body is borne upon the 
affected limb ; in both cases, also, the foot can be more or less 
everted; notwithstanding, however, this close similarity, the 
diagnosis is simple, for the very circumstance of the one being 
a congenital defect, is enough to distinguish between them. 
The recurrence of the displacement, and consequent short* 
ening of the limb, when the extending force ceases to act, 
might perhaps induce some to look upon the case as one of 
fracture of the neck of the femur, with inversion of the foot; 
but we have so many diagnostic marks between these accidents, 
that such an error would be almost inexcusable ; it is, no doubt. 



238 Mr. RusselPs Case of Hydatid Tumour. 

^rue that in both cases the patient can evert the foot to a certain 
clegree, and in both there is crepitus; but in the former case, 
tehen we rotate the limb, the integrity of every portion of the 
femur is manifest, the trochanter moves in the segment of a much 
larger circle than it does when the neck of the femur is broken, 
and the shortening of the limb, after the extending force is with- 
drawn, occurs at a much later period, and may perhaps, by 
proper treatment, be altogether prevented. 

Mr. Scott has published a case,* in which the upper part 
of the brim of the acetabulum was broken, and the head of the 
femur displaced upon the dorsum of the ilium, the limb was 
shortened two inches, and the toes turned inwards, and it wais 
remarkable that the motion of rotation outwards, though painful 
and diflScult, could, to a certain extent, be accomplished. 

I think, therefore, that we may state the diagnostic signs of 
this injury to be the crepitus, the degree of motion being greater 
than in luxation, the possibility of everting the foot, the re- 
currence of the shortening some time after the extending force 
has ceased, and the consequent re-appearance of the original 
symptom ; it is an injury exceedingly difficult to treat, and very 
liable to be succeeded by permanent lameness. 



Art. XIII. — Case of Hydatid Tumour. By John J. Rvn^ 
SELL, Assistant Surgeon, 73rd Regiment. 

In the month of May, 1833, the following case was admitted 
into the Hospital of the 63rd Regiment, then stationed at Ho- 
bart Town* It was seen by several surgeons of the place as well 
as by many naval surgeons, who occasionally visited the port* 
Its nature and exact situation were, prior to the operation, mere 
matter of conjecture to us. There is a case recorded of much 
resemblance to it in the Medico-Chirurgical Review of Janu- 
ary, 1828. 

* Dublin Hospital Reportti vol. iii. 



Mr. Russell's Case of Hydatid Tumour. 239 

May 18th. George Aram, 63rd Regiment, master tailor, 
«t. 36, a pale, unhealUiy looking man, prone to excessive indut 
genoe in liquor, admitted, complaining of an obtuse pain or un- 
easy sensation in the epigastric region, somewhat increased by 
pressure. On close examination, there can be indistinctly felt 
a tumour projecting from under the ribs of the right side of the 
thorax, extending to about two inches to the left of the en- 
siform cartilage, and descending a little below the umbilicus, 
apparently as if it were an enlargement of the left lobe of the 
liver. Tlie affection, he states, has been coming on for several 
months, but not giving pain, he did not attend to it The ac- 
tion of the boweb is very irregular ; evacuations sometimes 
scanty, pale, or slimy, at others confined for two or three days 
together ; countenance sallow, exhibiting in appearance that of 
a man affected with chronic hepatitis ; pulse weak, and but 
little accelerated ; appetite capricious ; he frequently has a sense 
of fulness in bis stomach, 

A cathartic of calomel and rhubarb was given, and cloths, bbh^ 
torated with a lotion of nitro-muriatic acid, were frequently ap« 
plied over the tumour. 

30th. Within the last three days, the tower part of the aln 
domen has become enlarged, and now a fluctuation is obscurely 
felt, bowels are open, stools oream-coloured ; no apparent alte- 
ration, in the tumour itself. 

Persistat In usu Solut. Acid. Nit. Muriat. 
R Subm. Hyd. gr. ii. 
Pulv. Scill» gr. ill. 
Digit, gr. i. 
M. ter in die sum. 

June 3rd. Tlie tumour increases, extending an inch below 
the umbilicus ; on the right side it becomes less distinct, but 
more prominent in the centre ; the distention in the lower part 
of the abomen subsides ; evacuations more natural ; pulse 
regular. 



240 Mr. Russell's Case of Hydatid Tnmotar. 

Omittr. Solut. Acid, affricetur tumori Ung. Hyd. Camphor, mane 
nocteque. Cont. Pil. 

6th. No apparent alteration in the tumour ; gums affected 
by the mercury ; bowels regular. 

Omitt. Prepar. Hydrarg. Affricetur pars affect. Liniment. StimuL 

9th. Tumour stationary ; the effusion into the lower part of 
the abdomen altogether absorbed ; he becomes more weal^ly 
and emaciated ; appetite continues good^ pulse natural^ tongue 
clean^ sleep much disturbed^ bowels regular, stools again cream- 
coloured. 

Sumat Confect. Opiat. 39s. h. s. cont. linim. 

15di. The colonial surgeon, and several other medical men, 
were invited to see this case by Surgeon Bohan and me, that we 
might have the advantage of their opinions, but they were unable 
to come to a positive conclusion as to its composition or precise 
situation, some considering it to have its seat in the omentum, 
and others in the liver,' or on its inferior surface. I am inclined 
to the latter opinion. It has assumed a circular form, extend- 
ing from the scrobiculus cordis to about two inches below the 
umbilicus, the exact border is undefined ; pressure on the cen- 
tre communicates an indistinct sensation of a fluid. 

Applicr. Cataplasma quater in die. Cont. haust. sed. h. s. 

17th. No change in appearance of tumour. Complains of 
being very restless at night. Bowels confined, tongue foul. 

Sumat. Haust. Purg. statim. 
R Liq. Opii sed. M. xxv. h. s. 

21 st Cataplasm produces no sensible effect. 

July 6th. The tumour becomes more circumscribed gene- 
rally, it is about the form of an inverted saucer; a portion of its 
inferior margin is felt like a firm ridge, extending transversely 
from two inches below the umbilicus, towards the anterior supe- 
rior spinous process of the right ilium. Its centre gives a sense of 



Mr. RusselFs Cane of Hydatid Tumour. 241 

fluctuation rather more distinct, with some elasticUy. Bowels 
inclined to constipation. 

Rep. Haust. Aperiens. Cent. Haust. sed h. s. 

14th. The swelling is now much increased and more conical ; 
its centre projects, and gives a sense of fluctuation; the limits of 
its circumference are the same, but the integuments are tense 
and glossy, bowels inactive, countenance of a sickly pallid hue, 
considerable debility, nights restless, patient's mind anxious, 
and he appears to participate in the general curiosity to ascer- 
tain the contents of the enlargement. Being almost certain 
that some fluid was contained in it, and from the anxiety of the 
patient, I determined to open it. In the presence of Messrs. 
Bohan, Scott, and Seccomb, I made an incision two inches 
long, in a straight line midway between the umbilicus and 
ensiform cartilages, which point was the apex of the conical 
projection through the integuments and through a thin cyst, 
on the opening of which an immense gush of perfectly formed 
hydatids took place, and continued, with the assistance of gentle 
pressure, to pass out for a considerable time. They were qf 
various sizes, some nearly as large as a goose's egg, down to thie 
size of the smallest pea. Many were broken in passing out. 
The quantity discharged (being counted by the Hospital Ser- 
geant till he was tired) amounted to nearly two thousand; and 
measured, with the fluid, which was mostly the contents of the 
broken hydatids, a gallon and a half. They were spherical, 
heavier than water, their fluid like the white of egg, but not 
coagulable by heat. A piece of lint introduced, and light 
dressing and bandage : — 

Sumat Vini Rubri Jz. 
Habt. Haust. sed. h. s. 

During the time of the escape of the hydatids, and after the 
first alarm was over, it was amusing to observe the patient's 
surprise, who innocently inquired, " be they eggs, Sirf I in- 
troduced two fingers to clear the passage, which was obstructed 
VOL. XII. NO. 35. 2 I 



B^ Mr. Ru8sell*8 Case of Hydatid TVunovn 

by the gush, and distinctly felt the projection of the ipisie with 
something which I took for the pancreas at the back of the 
cavity. 

July 19th, TTiis morning fourteen more hydatids came away 
with the dressings ; their coats appeared more diick and less 
translucent than the first Sleeps better, appetite pretty good, 
bowels regular, mind more tranquil : 

Continue anodyne, wine> and pudding. 

22nd. Twelve more hydatids escaped, their surfaces covered 
with a yellow, viscid matter resembling bile. 

Cont. med. 

28th. Six more escaped, so yellow as to appear like yolks 
of eggs. Debility. 

Cent, omnia Med., kc. 
27th. Ditto. 

Sumat Quin» Sulph. gr. iii. ter in die. 

August 18th. PectUetU matter of an intolerably offensive 
smell has come away daily for the last fortnight, with an oc- 
casional hydatid or bit of membrane, and this morning, for ttie 
first time, about three drams otpus escaped. 

22nd. The discharge which comes away daily now, is at 
first of a serous description, it then becomes purulent* mixed 
with dark-coloured viscid matter, and amounts to a pint; the 
odour is very offensive, but no purulent matter has appeared 
for the last two days. The patient's general health improves, 
he now occasionally walks about the ward, appetite continues 
good, bowels regular : 

Cent, omnia. 

31 St. General health improving; discharge is about twelve 
ounces daily otpus and serum. 

September 20th. Discharge about half a, pint daily; be* 
coming less and less offensive ; health improves. 

November 1st The discharge has come down to about two 



Dr. Corrigan on Aortitis, ^. 243 

ounces at each dressing ; improved in all respects^ but retains 
bis pallid countenance^ with a slightly csdematous appearance. 

December 13th. The dressings require changing daily, but 
the discharge is very slight. The patient walks about in the open 
air ; his spirits and appetite are good, and he may be considered 
convalescent. This man being unfit for active service has been 
discharged with a pension to remaia in the colony. I heard 
lately that he was well and enjoying tolerably good health, 
three years after the operation for his relief. 



Art. XIV.— Q» Aortitis, as one of the Causes of Angina 
Pectoris; with Observations on its Mature and TreaU 
ment. By D. J. Corrioan, M. D., Lecturer on the The- 
ory and Practice of Medicine, at the Dublin School of 
Anatomy, Surgery, and Medicine, Physician to Jervis-street 
Hospital, Dublin, Consulting Physician to the Royal Col- 
lege of St. Patrick, Maynooth, &c. 

I HAVE two objects in view in these observations, 1st, to shew 
that inflammation of the lining membrane of the mouth of the 
aorta is capable of producing the group of symptoms to which 
we give the name of Angina Pectoris, and is therefore entitled 
to a place in the list of the causes of that formidable affection ; 
2ndly, to trace the pathology and treatment of aortitis. 

I shall relate the cases in the order in which I believe 
they will throw most light upon the disease, first giving the 
cases in which the patient died, while the disease was acute 
or recent, then those cases of longer duration, which exhibit 
the alterations of structure produced by the disease, when un- 
controlled in its progress, and lastly, those cases in which, from 
analogy with the symptoms of the former cases, there was every 
reason to suppose the existence of the disease, and in which, 
treatment founded on the supposition was attended with success. 

Of the first class of cases, or those exhibiting the pathology 
of disease in its recent or acute stage, there is a good instance 



244 Dr. Corrigan on Aortitis, as one of the 

in PortaFs Anatomic Medicale^ vol. iii. p. 127. A young man; 
ill of small-pox^ died of the disease suddenly receding. The 
symptoms were violent suffocations^ accompanied with palpita- 
tion. The aorta, through its whole extent, was very red, its pa- 
rietes swelled and soft, particularly in the thoracic region, where 
the artery was covered with varicose vessels, and its internal 
membrane was swollen and softened. 

The second. is from Bouillaud's recent work on Diseases of 
the Heart, Appendix, p. 372. A young man, ill of typhoid en^ 
teritis, was seized with great agitation, accompanied with diffi- 
culty of respiration, and disturbance of the circulation, and died 
suddenly with these symptoms, such as are not usually met witli 
in fever. On dissection, the aortic valves were found covered 
with a thin granular false membrane. This fibrinous mem- 
brane could be torn off like that found in pericarditis or pleu- 
ritis. The layer in contact with the valve seemed already or- 
ganized, and there can be scarcely a doubt, that in some days 
it would have become adherent to the valves, and would have 
produced thickening. On the surface of the valves, as well as 
on the lining membrane of the aorta, there were red points^ 
and below the valves the lining membrane of the ventricle was 
opaque and milky. 

The following cases came witliin my own observation. 

Cask L- Glynn, aetat. 39, carpenter, was admitted 

into Jervis.street Hospital on the 19th June, 1837. He vras 
under the care of my friend and colleague. Dr. Hunt, to whom 
I am indebted for this [case. He had been complaining for 
three months previously of debility and cough, accompanied 
with attacks of dyspnoea, attacking him when walking or work* 
ing, and obliging him to stop frequently to sit down. He also 
suffered acutely from sensations as if of tearing asunder in hia 
chest.* After exercise he suffered from palpitation. 



* ** II semble au malade que des ongles de fer on la grifie d*un animd lai 
dechireot la patUe aoterieure dc la poitrioe.'* — Lasmnsc. 



245 

dulness 
tact ac 
but no 
nission, 
lelirium 

e whole 
Inrlyso. 
tesj was 
beyond 
f or^n- 
tand tha 
I portion 
bed sur- 

Iry, iur- 
r him in 
me; the 
ne erea 
' great*^ 
tier pre- 
ris. He 
lyspnoea, 
tpresuon 
Ihesepa- 
ind had 
nn wbea 
ren when 
>Iiged to 
py, even 
pitB, and 
i stooped 
g the BO- 

j with Dr. 
! ulicle on 



244 

in Portal' 
illofsma 
symptom! 
tion. Tl 
tietea swe 
(he BrtCT} 
membrani 
Thes 
the Heart 
teriUs, na 
cultyof re 
suddenly 
in feyer. 
with a tb 
brane cou 
rilis. Th 
gaalzed, a 
it would b 
produced 
on the lii 
and beton 
opaque an 
Theft 
CasbI 
into Jervii 
under ttie 
I am inde 



Causes of Angina Pectoris. 245 

' Physical examinaiion of the chest gave extensive dulneas 
over the precordial region^ with tumultuous and indistinct ac- 
tion of the hearty and puerile respiration in the lungs^ but no 
other sign of disease. On the 24th, five days after admission, 
bead symptoms set in^ viz.^ dry retching, followed by delirium 
and stupor, and he died on the 26th. 

P. M. There was some fluid in the pericardium ; the whole 
heart was enlarged, the left ventricle and auricle particularly so. 
The lining membrane of the aorta, just above the valves, was 
of a vivid red colour, and was protruded considerably beyond 
the natural level by an efiusion of red, and (apparently) organ-^ 
ised lymph, which lay behind it, effused between it and the 
fibrous coat of the vessel. This vividly red and swollen portion 
of the vessel contrasted stron^y with the pale and polished sur- 
face of the artery a little further on. 

Casb II. — The case of the late Mr. T., an apothecary, fur- 
nished me with the next instance of the disease. I saw him in 
May, 1837, when he walked into my study to consult me ; the 
dyspncea was most distressing, and painful in the extreme even 
to look at ; his face was pale, and expressive of the greatc^ 
anxiety; his pulse quick and small, and he altogether pre- 
sented a distressing picture of intense Angina Pectoris. He 
came, he said, to seek for relief from paroxysms of dyspnoea, 
which were accompanied with feelings of great oppression 
across the chest, and sensation of impending death. These pa- 
roxysms commenced about five or six months ago, and had 
latterly become very frequent He is seized by them when 
walking in the street, when stooping to tie his shoes, even when 
lying in bed. If seized by them when moving, he is obliged to 
hold by any thing within reach, and to abstain from any, even 
the slightest attempt at any further exertion. He pants, and 
dare not lie down, if in bed, but is obliged to remain stooped 
forward as long as the paroxysm lasts.* On examining the ac- 



* The Bymptoms of a paroxyim in this cue coincide accniatelj with Dr. 
Forbcs*s description of a paroxysm of angina, given in his admirable article on 



246 Dr. Corrigan on AartUUt oi one of the 

tion of tbe heart, I found it strong, with intense bruit de soufflet 
under the first bone of the sternum, and below the left mamma. 
When the paroxysm was not on him, the pulse was full, uid 
about 100. In this instance, assisted by the cases I had pre* 
yiously seen, I made the diagnosis for the first time, and referred 
the paroxysms to inflammation of the lining membrane of the 
mouth of the Aorta ; I treated him on this supposition. Leech- 
es were applied over the region of the heart, followed by blis*' 
lering; and blue pill was given in small doses, until the mouth was 
made sore. To arrest the paroxysms, which it was generally suc- 
cessful in doing, a draught was given of Sss. of laurel water, 
with fifteen drops of Tra opii, and three or four grains of camphor. 
As soon as the mouth was made sore, he was put on digitalis. 
Under this treatment the amendment was rajHd. At the end of 
a fortnight the fits of dyspnoea had ceased, the pulse fell to 
seventy ; and, to use his own expression, he felt that he was quite 
well. The bruit de soufiSet, though much less intense, continued 
quite audible. Just, however, at this time, when all seemed so 

die cBietse, in the Cyclopedit of Pnctical Medicine. " Whilst walking or ran* 
ning» end mora ptrticnlarly if in the act of ascending an elevation at the same 
tinie» he it aU at once leiied with a most distraeaing sensation in the chest, osv* 
ally in the legion of the heart, or abont the lower half of the steraam, and towards 
the left side. This sensation is varioosly described ; as pressure, or stricture, or 
weight, or u a positiTe pain of Tarioos character and degree, sometimes obtuse, 
aomes acute, tearing, burning, or lancinating. There seems always to be some* 
thing peculiar in the pain, whaterer be its degree, unlike the pain of other 
parts of the body, and, as it were, combined with something of a mental qua* 
lity. Thera is a feeling, a fear of impending death, and the primary symptoma 
of corporeal disorder are speedily modified by the consequences of mental impres* 
aions, couTeyed through the nervous system. The patient makes a sudden pause, 
eagerly catches hold of whatever is next him for support, perhaps raises the hand 
to some object above him, to which he clings, or it may be, imperceptibly sinks 
down on a chair or bank, u if unslble to stand, yet afraid of the movements 
necessary to seat him. The face is pale, the expraasion of the counttsance hag* 
gard, the whole body is covered with a cold sweat, and death appears to be im« 
peodisg, no less to the iiieiperienced spectator, thaa to the miieiable patasau" 



CamcB of Angjtna Pectoris. 247 

favourable^ the change was awfully sudden. He bad gone to 
bed as well as usual^ when after having been lying but for a 
short time, he suddenly sprung out of bed, exclaimed that he 
was gone, fell back, and expired. I examined the body next 
day. The lungs were healthy ; the heart was larger than usual, 
and considerably distended ; the right cavities were sound ; the 
aorta was now slit open ; the portion of it near the arch was 
thickly studded with irregularly shaped small patches of a white 
colour : these patches were under the lining; membrane, and 
scarcely elevated it. But the most remarkable appearance was 
in the portion of the aorta forming its mouth, and in the valves. 
For a space of from one-half to one inch above the valves, the 
interior of the aorta was of a vivid deep velvet red, contrasting 
very strongly with the ordinary pale colour of the vessel higher 
up ; and between the deeply coloured portion and the healthy 
part the line of demarcation was quite abrupt The lining 
membrane, covering the highly vascular part, felt pulpy to 
the finger, and protruded beyond the healthy surface by the 
height of one-eighth of an inch ; this protrusion was caused by 
the effusion underneath it of a gelatinous effusion, lying between 
it and the middle coat of the vessel* The immediate cause of 
death was also revealed. One of the semi-lunar valves was rup«- 
tured, and evidently recently, for the rupture was jagged and 
irregular, and sharp at the edges. This valve was singulariy 
formed. It was like a little pouch, or the finger of a glove, project-^ 
ing down into the ventricle ; the bottom of this poudi had gives 

* The appearances in this case corresponded preUy nearly with the description 
of the pathology of acnte arteritit, given by Mr. Porter, in his paper on Internal 
Anenrisni, in the Dablin Jonmal for NoTember, 1833. Hb description » this :— 
" The lining membrane of the aorta was of a bright crimson or carmine colonf» 
nused with smaU spangles, like patches of a paler and more opaqne tint. This 
rascnlarity resided principally in the lining membrane, for on stripping off a por* 
tion of it, the fibrous tissue, although evidently inflamed, was much paler. The 
patches above mentioned were caused by deposition of a soft, white, cheesy sub* 
stuice* which were either in the linbg membrane, or between it and the fibrous 
coat; it came off attached to the liniofawUmiMt." 



248 Dr, Corrigan on Aortitis, cu one of the 

way, and the heart was distended by tlie blood which bad retro- 
graded into it from the aorta. The texture of all the valves was 
thin, but healthy. 

These two cases of Glynn and T. are, I think, particularly 
instructive, the patients having died of other diseases, while the* 
change going on in the aorta was in what may be called its acute 
stage. Glynn died of disease of the brain, while Mr. T. evi- 
dently died in the syncope produced by the sudden rupture of 
the aortic valve. 

These four cases constitute what I have called the first class 
of cases which shew us the disease in its recent state, and before 
any alteration of structure has as yet taken place, when as yet 
the change consists only in sub-membranous eflusion, or in 
deposition of lymph, either of which may be removed. The 
following cases shew us the disease when it has gone so far as to 
produce irremediable alteration of structure, either in the aorta 
itself or its valves. 

In October, 1832, 1 saw Mr. Flanagan, setat. 45, a respect- 
able manufacturer. He was then dying with the usual symptoms 
and physical signs of permanent patency of the aorta, accompanied 
with effusion to great amount into both pleurae. The symptoms 
it is not necessary to detail. The commencement or the 
onset of his illness is the most interesting to us at present 
About three years before this period he was attacked with what 
was supposed to be nervous angina. He was frequently seized, 
particularly when walking, with fits of dyspnoea and palpitation, 
accompanied with pain or oppression, referred to the region of 
the heart These attacks obliged him to stop and take rest, 
until the fit passed ofl; The attacks became gradually more 
frequent, and at length the organic disease under which he sunk 
shewed itself unequivocally. 

On dissection, the semi-lunar valves of the aorta were found 
perforated and cartilaginous, and the lining membrane of the 
aorta, from the mouth of the vessel to its arch, contained under- 
neath it innumerable atheromatous depositions. 



Causes of jingina Pectoris. 24d 

In this case it is hard to resist the conclusion^ that had the 
fits, erroneously supposed to be nervous angina, be^ referred 
to their true cause, thb inflammatory action going on in the 
mouth of the aorta might have been arrested and life have been 
saved** 

Of the third dass of ca^, or those illustrating the treats 
ment, I have as yet but two instances, but those are satisfactory. 

In February, 1835, Mr. D. passed through a very severe 
attack of acute rheumatism, and in the course of it was frequently 
seized by what were supposed to be fits of spasmodic dyspnoea. 
* I saw him in his convalescence. He was sufiering little from 
articular pains, but there was very strong action of the heart, 
with indistinct bruit de soufflet, and exercise brought on severe 
palpitations. I warned him of his danger, but in vain. He was 
so impressed with the conviction of his heart symptoms being 
nervous, that no persuasion could induce him to submit to treat- 
ment conducted on any other supposition. In eighteen months 
afterwards he came to town to consult me ; his lips were livid and 
his feet oedematous, and he was suffering from severe and frequent 
paroxysms of dyspnoea. He dreaded to lie down, and the fits 
of palpitation and dyspnoea were brought on by any exercise, 
but more particularly by attempting to walk up an ascent 
The abdominal organs were sound. The chest sounded well 
on percussion ; and the respiration was, in every part, natural 
or somewhat peurile. The pulsation of the heart was felt over a 
large space With strong impulse, and there was vety slight bruit 
de soufiSet in the proecordial region ; pulse was about eigh^-five 
and small. These were the symptoms on the 4th of August, 

* Through the kindneis of Dr. Marsh, I saw a case very similar, io which 
the symptoms were also those of aDgina pectoris, accompanied with acute pains 
shooting to the shoulders. The patient, io addition to presenting the usual signs of 
permanent patency of the aortic opening, soffered dreadfully from fits of dyspnoea, 
agitation, and excesahre distress. On dissection the aorta was Ibond studded all 
ever in its arch and asoeoding portion with white cheesy or fibrinous spangles, it 
was dilated and its textnre was softened. 

VOL. xn. NO. 35. 2 k 



250 Dr. Corrigan on Aortitis, €u one of the 

1836. Leeches were applied over the region of the heart, and 
ten grains of Hyd. c. Magnesia, given three times a day ; while 
abstinence from wine and from stimulant antispasnlodics wite 
atrictly enjoined. A seton was inserted below the left mamma. 

In four days the mouth was made sore, and the change in his 
state was as gratifying as it was rapid. The breathing became 
easy, the fits of dyspnoea ceased, and he slept without disturb- 
ance and without dread in the recumbent posture. 

On the 22nd I again made his mouth sore. He then re- 
turned home, and has never had any return of his former dis- 
tressing symptoms. While these sheets are going through the 
press, October, 1837, 1 have again had an opportunity of seeing 
him. He is in perfectly good health, after having undergone 
the exciting and arduous exertions attendant on taking an active 
part in two of the most violently contested elections in the 
kingdom. 

Collins, «tat. thirty-eight, was admitted into Jervis- 

street Hospital on the 8th of July; 1837. His feet, face, and 
hands were slightly cedematous, and his countenance was pecu- 
liarly anxious in its expression. He complained of frequent 
coughing, but what distressed him most were attacks of palpi- 
tation and oppression in his breathing. These paroxysms were 
frequent in the night, and for the fortnight before admission 
he scarcely ever lay down, his dread of their coming on was so 
great. His pulse was regular. The respiration was natural 
through the chest, and no trace of disease could be detected in the 
kidneys or digestive organs. It was only on accurate examination 
of the heart, that slight bruit de soufflet was discovered. It 
became more audible on making him take a few turns round 
the ward. He was leeched and blistered over the region of the 
heart, and put upon blue pill. His mouth became sore at the 
end of three days; and, in a week from his admission into hos- 
pital, the oedema had disappeared, the fits of dyspnoea and 
orthopnoea had ceased, and he was free from every inconvenience 
except that produced by the sore mouth. 

I have not dwelt on the cautions requisite to be observed in 



Causes of Angina Pectoris. 251 

making the diagnosUof this disease. These cautions will occur to 
every experienced and practical stQthoscopist. It is obvious that 
where^ as in the cases related^ there isbutone jx^iresymptoin, 
viz.> the recurrence ofBts of angina, the diagnosis must depend 
very much on negative evidence, and that to arrive at the diag- 
nosis of the disease, we must most carefully ascertain that there 
is no other disease in thorax, abdomen, or head, to which the 
fits of dyspnoea can be referred. In this disease, as in pericar- 
ditis, we must often arrive at its diagnosis rather by ascertain* 
ing that other diseases, which might give rise to similar symp- 
toms are absent, than by the suflBciency of direct signs produced 
by the disease itself. 

There are some circumstances connected with the diagnosis 
of the disease, which it may, perhaps, be well to notice, as they 
might be calculated to mislead. It would not be expected a 
priori, that without sufficient mechanical obstruction, inflamma- 
tion of the lining membrane of the aorta should produce fits of 
dyspnoea. The same circumstance, however, is observed in 
pericarditis. It is not unusual to see patients in the progr^s of 
acute rheumatism, suddenly seized with pericarditis, and pre- 
senting dyspnoea as the only positive symptom of the attack^ and 
until recent investigation gave us the valuable aid of physical 
signs, in revealing the true cause of those fits of dyspnoea, they 
were too often treated as nervous paroxysms, and sudden death, 
or a lingering heart disease, was the consequence of the mistake. 

The observations of Andral, on a case of pericarditis, con- 
firm the observations made here on the connexion between in- 
flammatory affections of the heart, and dyspnoea, as a symptom 
of them. 

*^ Dans le cas qui vient d'etre cild, la dyspn^e est le seul signe 
qui reste, comme pouvant annoncer qu'il y a affection des or- 
ganes thorachiques : en procedant par vote cTexclusion, comme 
nous I'avous dejk dit, ou pent encore, dans ce cas, arriver a 
reconnaitre, ou du moins a soupqonner Texistence d'une peri- 
cardite." The occurrence then of fits of dyspnoea, as a symptom 
of inflammation of the internal serous membrane of the aorta or 



e*^ 



S52 Ih. Cortigfin en Aoriitiai ki MB of the 

heart, is'in analogy with what we observe of it^ as a symptom ift 
inflammation of the external serous membrane. 

The recurrence of the symptoms in paroxysms is anothef 
circnmstance calculated to lead an observer away from the true 
nature of the disease, inducing him to suppose, that where th^ 
symptoms are transitory, the diseased action producing them 
could not be permanent; but this connexion of persisting disease 
with intermittent symptoms, is only one of a vast number of 
similar examples that might be adduced. The paroxysms of 
dyspnoda, in confirmed valvtilar diseases, the epileptic paroxysms 
dependent on tumors in the brain, or chronic meningitis of the 
spinal cord, the spasmodic colics accompanying mesenteric 
disease, are all similar examples of persisting diseased action 
giving rise to intermittent symptoms.^ That tlie usual consti- 
tutional febrile symptoms of local inflammatory action were not 
present in the case related, will not surprise any one conversant 
with the diseases of the thoracic organs, in which it so often 
occurs, that violent inflammation or efllision may occur without 
what are ordinarily called the constitutional symptoms of local 
inflammatory action. The non-accompaniment of Coristituti<Mial 
symptoms does not alter the nature of the diseased action, 
neither must it forbid the requisite treatmentf 

In summing up the cases which I have related, I think I 
may be justified in drawing these conclusions : 

* The occurreoce of lymptomt rach u are detoribed, coming oo in ptroxjsmt, 
■eemt to have a more intimate connexion with aortitis than has perhaps been 
hitherto suspected ; and this connexion would seem to extend to aortitis generaUj. 
Bertin, p. 36, gives the case at length of a woman, setat. 47, who, for two years, 
suffered under symptoms, supposed by all who saw her to be nervous spasms, and for 
which she was unsuccessfuly treated by antispasmodics. On post mortem examina- 
tion, the whole tract of the aorta was found inflamed with deposition of lymph, &c. 

t Mais la marche differente d'une maladie n'en change pas la. nature : aoit 
done que les diverses alterations de la membrane interne ducoeur anient precedees 
dans leur formation par des symptomes manifestos d*inflammation soit que ceux ci 
restent latens, leer cause leur origine premiere ne nous seroblent pas devoir etre 
regardees comme differentes. — Andhal, C Unique MedicaU, vol. i. Maladia d$ 
Poitrin%, p. 54. 



.»- ->-. 



•'^ v\ Cawei of Angina Peciorii. iSi 

-' 1st 'AiAt in sofne ca8e#l)f wtiait ard called Angina F^^toris 
(he paroxyitos of dyspnoea^ anxiety, mental distress, &c. consti- 
tuting a fit of Angina Pectoris, and often suppo^d to te merefy 
nerrous, are really the symptoms of aortitis, bt inflaitimation 
6f the mduth of the aorta. '' 

2nd. That the treatment in sudi cises is the adoption of 
local bleeding, counter-irritatioti; and the exhibition of niercury, 
which exi^rience hto tatlght us are the Means best <»dculated 
to prevent the effusion or cause tiie absorption of lymph. 

The pathology of the disease, which these cases have en- 
abled us to* trace, encourages us also to put into requisition our 
treatmelnt, and to ^rsevere in it afler even a considerable lapse 
of time has passed by, in instances too where, without this khow^ 
ledge, we should have looked upon the case in despair/ from 
the belief that irremediable organic disease had been establidied: 
We learn from those cases, that the disease may remain for a 
very considerable time in its first stage, or that of effusion of 
lymph, without producing any organic alteration in structure* 
Thus, in the case of Glynn, three months had elapsed between 
the commencement of his illness and his death, and yet the 
diseased action had proceeded no farther than the formation of 
gelatinous efiuslon under the lining membrane of the aorta. In 
the case of Mr. T. six months had passed by, and yet the dis- 
ease was in the same stage ; and in the case of Mr. F. nearly 
three years had elapsed before the disease assumed its confirmed 
organic character, while, in the case of Mr. D. J. the appro- 
priate treatment was perfectly successful after the expiration of 
eighteen months. 

The detection of diseased action in the lining membrane 
of the heart or aorta in the early stage, while it is yet under the 
control of treatment, is a matter of great practical importance. 
Mr. Wardrop observes^ that ^ it remains an important deside- 
ratum to discover the means of discriminating diseases of the 
heart in their earliest stages, and before any of these formidable 
changes of structure have taken place, which it is not within the 
powers of medicine to remove. And the detection of these (the 



254 Dft Osbortie's Obsertatiotu on Neuralgia, 8fC. 

symptomg) will enable us to apply remedial mean^^ with a pro- 
bability of achieving the same advantages as in the treatment 
of diseases of the organs.** I hope the cases related here may 
contribute sdme little to enable us to make the diagnosis of 
disease in so important an organ at that early stage when the 
diagnosis can be practicably useful. 

The accompanying plate represents the disease. A is the 
portion diseased round the mouth of the aorta : tlie lining 
membrane being crimson red, turgid, and swoln out by an efili- 
•ion of lymph behind it. B represents a portion of the lining 
membrane of the ventricle, thickened, opaque, and milky, hav- 
ing evidently undergone a similar diseased action, but of longer 
duration. 

This latter aflfection or endocarditis, and its influence on 
the muscular action and tissue of the heart, will, I hope, when 
I shall have accumulated sufficient materials, form the subject 
of another communication. 



Art. XV. — Observations on the Nature of Neuralgia, and on 
the Principles, according to which the Treatment of it ought 
to be conducted. By Jonathan Osborne, M. D., Fellow 
of the King and Queen*s College of Physicians ; Physician 
to Sir Patrick Dun's and Mercer's Hospitals, &c. 

Neuralgia is a painful affection of a nerve, existing independ- 
antly of any morbid condition of the surrounding parts. That 
all pain is received through the medium of the nerves, is proved 
by the fact, that where they do not exist, there is no sensation ; 
by sensation in the healthy state, being very much in propor- 
tion to the supply of nerves sent to any given part, and also by 
the pain attending inflammation of certain parts, being generally 
in the same proportion while other circumstances are similar. 
The nerves, then, being the organs of sensation, and conse- 
quently of pain, every painful aflection may be said to be 
neuralgic* 



Dr. Osborne's Observations on Neuralgia, 8fc. 265 

The term is now> however^ by common consent, restricted 
to those cases in which there is no yisible disease in the seat of 
the pain^ and in which^ for want of any better explanation^ a 
primary affection of the nerves, as the organs of sensation^ is 
supposed to exist* 

It may very justly be reproached to physiologists, that when 
perplexed to account for any of the phenomena of the living 
body, they refer it to the nerves, in the same manner as chem- 
ists, when in a similar predicament, fall back oh electricity or 
galvanism. In the present instance the painful affection has 
been generally described, not only as an affection of the nerves, 
but as arising from irritation. Its history may be reviewed 
very briefly. It appears to have been first noticed by Andre, 
a surgeon of Versailles, in 1756, who related some cases of tic 
douloureux at the end of his treatise on the urethra, but they, 
from the unsuitable manner in which they were introduced, 
appear to have been quite neglected. In Dr. White's work on 
Nervous Diseases, published in 1765, painful affections in the 
direction of the nerves are very plainly pointed out, but are as- 
cribed to irregular forms of gout or rheumatism. From Dr. 
Fothergill's paper, published in 1775, (vol. v. Med. Obs. and 
Enq.) we are to date the distinct recognition of tic douloureux 
as an affection of the nerve. Chaussier and Halliday, in France, 
Meglin in Germany, and several observers in England traced 
the same affections in other nerves besides those of tlie face, 
and in the last edition of Dr. Mason Good's System, neuralgia 
of the face, the foot, and the breast, is distinctly recognized. 
The cause of the disease was suspected by Fothergill to lie in a 
cancerous diathesis. Dr. Trevor, of America, held it to be an 
inflammation of the periosteum of the part aflTected, wliile Co- 
tugni, having found an infiltration under the neurilema of the 
sciatic nerve in one case, and others having said that the nerves 
sufl^ring from it had been found red and swollen, it was for a 
time thought to be caused by inflammation of the neurilema. 

After a due consideration of the recorded facts^ and a com- 
parison of them with the cases under my own observation, I btive 



2$6 . Dr. Osborne*? Obsermiions on ^eurcdgta, 8ft. 

for flome time past arriyed at the oondosion, that the nature of 
neuralgia is altogether different from any of the opinions re- 
specting it now mentioned ; and that 'it is nothing else than 
pcm arismgjrom pwralym oftM nerpe efficient to af^ its 
mode of sensation, but not so complete cls to obliterate iL TIimb 
facts Rhich appear to me to support this vi^ of the subject are 
the following: 

1st An individual may at any time produce neuralgia in a 
nerve which is so situate as to be pressedon: for example^ let 
one leg lie over the other so as to compress the popliteal nerves. 
In due time total paralysis, both of sensation and motion, will 
he produced, and during the process of becoming paralysed, as 
well AS during that of being recovered from that state^ und at 
the same stage, of diminution of seaisibilify , a peculiar tingling 
sensation will be perceived along the nerve, often most acutely 
painful, which all the sufferers from neuralgic p^ins, wijth wboQi 
I have conversed, at once acknowledged to be, although traosjient, 
yet identical with what they suffer. 

2nd. The accompanying affections are of a paralytic characr 
ter ; witness its connexion with partial paralysis of the nerves of 
the face, which ofteu occurs, as in the case which I am about to 
relate^ and the same in the limbs,, of which I have an instance 
at present in Sir Patrick Dun's Hospital ; witness the neural- 
gic pains, chiefly in the lower extremities, which are observed m 
low fevers, when the patient is emerging from a state of coma; 
witness also, the pains of the same kind (sometimes fatally mis- 
taken for ^ying gout) which occur in old persons, and which 
are the result of a slow process of disorganization .of the brain* 
sooner or later to be manifested more clearly, by gradual Ipsa of 
memory^ and at length by those well marked paralytic symp- 
toms, which belong to softening of the nervous structure. 
. j3rd« The adjuvantia and Icedentku For the alleviation 
of pain, we are instinctively directed to the use of sedatives^ 
wd in neuralgic affections, there is no doubt that they have 
had an ample trial. But though their jbilure is so well knOwn, 
that they are not now recommended with any confidence, yet 



Pr. Osborne's Observations on jyeuralgia, 8fc. 257 

jthis exception to the ordinary laws of the action ofremedies doea 
not appear to have engaged attention^ or even to have excited 
suspicion as to the true nature of the affection. All the well 
established remedies for the cure of neuralgia are of the tonic 
or stimulant class ; such are arsenic^ quinine^ iron, &c. If neu- 
ralgia be a state of excitement, it is contrary to analogy that it 
should be treated most successfully, as it is, by those remedies 
which are known to be most injurious in all other states of ex- 
citement The obvious conclusion is, that it is not a state of 
excitement. 

4th. Inflammation of the nerve^ or rather of its sheath, is 
already well known, and marked by the appropriate symptoms, 
as pain constant, increased by pressure, accompanied by more 
x>r less heat and redness, together with a hardness, as of a cord, 
in the direction of the nerve, and is therefore an affection dis- 
tinct from that before us, and with which the latter ought never 
to be confounded. 

5th. The cases of neuralgia on record, in which irritation of the 
nerve was supposed to have been proved, in consequenceof the ap- 
pearances on dissection, are clearly to be explained by a state of 
pressure on the nerve, a pressure insufficient to producetotal para- 
lysis, and resembling that produced by one leg overlying another. 
I allude in particular to the case described by Sir Henry Halford. 
In this, a morbid growth of bone pressed on the trunk of the in- 
fra-orbitary nerve, when in the foramen. Nor is the case de- 
scribed Mr. Jeffiries less to be ascribed to pressure. *' A young 
woman, when only six years old, fell down with a teacup in her 
hand, which was broken, one of the cheeks lacerated, and a 
iragment of the teacup imbedded under the skin. The wound 
healed, though slowly, and with difficulty; the buried frag- 
,ment of the teacup was not noticed, and was consequently not 
extracted. From an early period, a violent nervous pain re- 
turned nightly, and one side of the face was paralytic. These 
dreadful symptoms were endured for fourteen years, at the end 
.of which time, an incision was made through the cicatrix, down 

VOL. XII. NO. 35. 2 L 



258 Dr. Odborne*s Observaticms on Neuralgia, 8f€. 

upon what was then found to be the edge of a hard substance, 
and which appeared^ when extracted^ to be the piece of teacup 
above noticed. From this time, the neuralgia and paraly»a 
ceased, the aflTeeted cheek recovered its proper plumpness, and 
Ae muscles their due power." Here the fragment of the tea- 
cup, if acting as an irritant, would have produced convulsive 
motions, instead of which it produced paralysis. Does not this 
argument, founded upon experience in other cases, lead to the 
conclusion that it acted solely by pressure ? I have had under my 
care, cases of fungus haematodes, and other morbid structures, 
gradually increasing, and pressitig oh the parts about the orbit, 
in which the neuralgic pains, shooting into the direction of the 
nerves, became less violent, and at length ended in numbness, ac- 
cording as the disease progressed ; a change (if my views are 
•correct) to be explained by the pressure producing, first, neu- 
ralgia, and afterwards, when increased, producing paralysis. 

6th. When neuralgia arises from disordered states of the 
stomach, dependent on indigestion, it is most agreeable to the 
-accompanying symptoms to consider it as a modification of pa- 
ralysis, for those symptoms are all of that nature. What are 
•die motes in vision but a transient form of amaurosis, in which 
so many spots in the retina are, for a time, rendered insensible 
to the rays of light. Deafhess is also at times an attendant on 
this state, while no one complains of morbidly acute vision or 
hearing, or morbidly increased energy of the moving or sensorial 
powers, as attendant on indigestion, although such idiould be 
expected if the neuralgia bdonging to it were in a state of ac- 
tual excitement 

In such an event as that described by Dr. Wollaslton, the 
• same analogy holds ; he having at a dinner party disordered his 
.stomadi, by eating of a certain dish, when he went to the draw- 
ing room was s^zed with a violent pain in the ankle ; he retired, 
vomited up the contents of his stomach, and was immediately 
relieved of the pain. In the mere dyspeptic patient die pre- 
sence of large quantities of the narcotic gases, especially carbo- 
nic acid and sulphuretted hydrogen, in the stomach and upper 



J>r. Osboroe'8 Observations on Neuralgia, ^e. 25S 

]x>rtion of the bowels; produces both motes in viisioii and head- 
ache. This state is always reliered by the excitement of taking 
food seasoned with aromaties into the stomadi, thus shewbg 
that those sensations really depend on torpor of the latter organ. 

7th. It appears reasonable to coander many pains not hitherto 
hdd to be neuralgic^ but which occur in local diseases as the 
results of imperfect paralysis ; for example, the well known 
accompaniment of soirrhus, namely, lancinating pains, coming 
on periodically. These haie all the characteristics belonging to 
neuralgia, and appear to be produced by the pressure of the 
gradually consolidated structure around them. A more violent 
and oor^uous pain is produced by ][»resspre in the case of ab^ 
aeesses forming under the fascia, and this immediately vanishes 
as soon as the pressure is renooved. Of the same kind are tlie 
pains, ofteo most eoEcruciating, attending the growth of anenrisBK 
of the abdominal aorta, especially in the neighbourhood of the 
eceliac axis, and in places where ordinary pressure is not produ& 
tive of pain. Pains in the ndes, in the direction of the intercostal 
nerves, which are notoriously refractory to leeches or counter^ 
irritants applied to the seat of pain, have of late years been 
foimd to yidd to the very same applications made at the ori- 
gins of those nerves. These affections have been called spinal 
irritation, without any adequate reason, inasmuch as no irritating 
cause can be assigned, and are rather to be viewed as the con- 
sequence of vascular congestion, pres^ng on the nerves at or 
near their origin, and thus caunng imperfect paralysis. 

8di. When the nerves are divided by a cutting nastrument, 
as in amputation, the pain felt by the patient is described as if 
the part divided was burned. Here, then, alAough irritation is 
iBHDediately applied to the trunk of a nerve, there is no sensa* 
tion, as of shooting down to the extremities. Afterwards, when 
the limb is in process of healing, die patient complains of 
various sensations referred to the amputated limb ; thus indivi- 
duals have been observed to scratch the extremity of a wooden 
leg, mistaking it for the foot. While those latter instances prove 



260 Dr. Osborne^s Observatiotu on Neuralgia, Sfe. 

that sensation is not in the nerve^ but at the nervous centre^ they 
at the same time, shew that a feeling can be excited, as if in a 
part, where, so far from nervous irritation arising, there are no 
nerves whatever, and this through the intervention of previous 
associations and recollections* 

0th. To avoid misapprehension, it must be observed, that 
by neuralgia we now understand that painful affection of the 
nerve, in which the pain proceeds from the trunk to the extre- 
mities, being in an opposite direction to that of ordinary sensa* 
tion, which is from the extremities to the nervous centre. W^ 
are not now treating of those cases in which pain along the 
course of a nerve is produced from injuries at their extremities, 
end which are undoubtedly the effects of irritation. To shew, 
however, how closely the two may be complicated, let us consi«> 
der an ordinary toothache from a carious tooth; here the 
pain is felt in the pulp of the tooth, and when irritating substan- 
ces are brought into contact, becomes excruciating, and then the 
pain shoots upwards, and resembles that which is felt at the 
moment of extraction. This is clearly pain produced by exter- 
nal irritation. When, on the contrary, the teeth being sound, 
and without any inflammation, a pain is observed to shoot 
downwards, not continuously, but at intervals, then the affection 
is strictly neuralgic, and if my views are correct, arises from a 
semiparalytic state of the nerve, induced either by the torpify* 
ing influence of cold, by indigestion, or by pressure. Both the 
neuralgic "and irritative pains will always be confounded from 
their often existing together at the same time in the same indi- 
vidual, 9nd the confusion will be increased by the fact, that they 
are sometimes removed by the one remedy, as for example, in 
the case now adduced, by the extraction of a tooth, or by exter- 
nal applications* 

10th. Many pains, which from their fugacious, and gene* 
rally transient character, appear to be neuralgic, are truly spas- 
modic, or to speak more rigorously, they occur in connexion 
with, and in proportion to a state of spasm. For example, the 



Dr. Osborne'a Observations on Neuralgia, 8fc^ 261 

pain in wry neck, and the shooting pain of lumbago. In 
rheumatic fever, the patient is sometimes more harassed with 
flying pains of this nature, than with any other circumstance 
attending the disorder. For those I have found an eminently 
successful remedy in belladonna, which, given internally, in 
half-grain doses of the extract every third hour, stops those 
pains, as by a charm, and in a manner the more remarkable, as 
it has no effect whatever in relieving the fixed pains, or in 
arresting the course of the disease. In some cases, however, as 
in that which I am about to describe, the spasm in the part af* 
fected by neuralgia was apparently produced merely by the vio- 
lence of the pain, which itself acts as an irritant, inasmuch as 
when the latter was to some degree relieved, the former entirety 
disappeared. 

11th. What appears to me, however, the strongest and most 
decisive argument that neuralgia is a torpid state of a nerve, is 
derived from the affect of acupuncture, which cannot be con- 
ceived to act in any way than as an irritant. Before I intro- 
duce to the notice of the reader a case of longstanding, rebellious 
to other means, and removed by this, and which I have selected 
as a specimen of its powers, I shall very briefly describe the 
most important facts relating to the history and mode of employ- 
ment of this remedy. 

The insertion of needles into the body appears not to have 
been practised bytheancient8,atleast no reference to it ison record. 
In India, however, it has been in use among the native practi* 
tioners, from an old date. Van Rhyne, a Dutch physician, who 
resided a number of years in the East Indias, first made acu- 
puncture known in Europe, in the year 1676, and Kempfer, 
in his Amoehitates exoticse, published in 1712, speaks of it as a 
remedy used in a species of colic by the natives of Japan. The 
process, however, was disregarded till 1810, when Dr. Berlio? 
published his observations.* Within a few years, a variety of 



* Memoire sur l*Acapunclure, Jour, de Leroux xxzf iii. Memoire sur le Mala- 
dies Chroniques les EvacuatioDi SaDgu'mes et I'Acupuncturci 1817. 



262 Dr. Osborne^s ObtenxUiona on Neuralgia, ^e. 

obserTattons were made on tbe subject in diflferent parts of Eu* 
rope^ and in 1825^ Mr. Chnrcbill introduced tbe remedy to tbe 
BritiA public^ in bis Treatise on Acupuncture. From this 
period^ we find in the medical journals^ a great number of cases 
of cure reported to bare been performed by acupuncture^ in 
circumscribed rheumatisms^ neuralgia, pertinacious hiccup, head^ 
ache, toothache, gastrodynia, lumbago, epilepsy proceeding from 
a fixed point, trismus, painful aflfection of tl^ teitides, intermit- 
tent fi9yers, gout, hooping-cough, ophthalmia, painter's ccdic, 
atiasarca, hydrocele, amaurosis, worms, arid tympanites. In a 
short time it has followed the course and shared tbe fate of 
many yaluable remedies ; it became a ftshion, has been recom- 
mended in the most varied forms of ^iaaase, has in tbe majority 
been found not to answer, and is now very nearly laid aside. 

The needles used by the Chinese are of g(4d <ir silver, and 
are inserted by means of a small hammer. In £#urope, sted 
needles have been preferred.* I find well tempered sewing nee- 
dles, of small diameter, with or without small balls of sealing- 
wax attached to the top, to answer very well, and such are much 
better than those with metal tops, as the weight of the lator 
eauses them to shake after being inserted, and thus produces a 
disagreeaUe sensation to ihe patient By some, they are in- 
serted by a rotatory motion with tbe fore-finger and thumbw I 
think it, however, preferable to insert them at once, it being not 
only less annoying to the patient, but also more efficacious^ 
The pain is very trifling, being nearly confined to the skin, and 
if ttie patient's attention is otherwise directed, and pressure 
made by the hand abo^ the point of insertion, it scarcely ex^ 
ceeds the sensation produced by the prick of a pin. In fact, 
this process of acupuncture is often performed in uport, by 
schoolboys on each other. With respect to the depth of the in- 
sertion, it has been ascertained by the observations of several 



* For some ingenious observations oii fbe employment of electricity by nee- 
dles, by Mr. HtmiHon, see the pages of this Jonmal. 



Dr. Osborne's ObservoHans on JSTeuralgia, 8fc. 263 

Frendi experimenters, that a needle may perforate every tissue^ 
even the articulations, the nerves, the parietes of the stomach and 
intestines, and the arteries, without any injurious result. Passing 
over Carrero, who has detailed cases of animals asphyxied, and 
restored to life by acupuncture of the heart, we find Clo* 
quet passing needles through the lungs, the liver, the testicle 
and the intestines, with perfect impunity. I have little doubt 
that I have repeatedly transfixed some of the larger arteries, 
and yet no un{deasanC consequence has ever resulted. Then9 
is, however, one observation, which with me has been without 
any exception, it is that in an inflamed part, or a part occupied 
by rheumatism, properly so called, the operation increases the 
pain, and aggravates the symptoms, and my conviction is, that 
if ^ remedy had been confined to genuine cases of neuralgia, 
in which alone I have found it beneficial,* it would have main- 
tained and increased its neputation, and would, at the present 
time, rank as one of the most valuable additions made of late years 
to the European practice of medicine. 

In applying acupuncture the object should be to transfix the 
nerve, and in my first set of cases many repetitions vrere required, 
in consequence of this not having been efiected. In sciatica, in 
which the patient, when asked to point out with his finger the 
direction of the pain, gives a correct anatomical demonstration 
of the course of the nerve from die outside of the hip to the 
ankle, it is expedient to follow his finger vritb a pen, marking it 
distinody, and then to insert the needles in the line marked. 
Their number may vary firom ten to thirty, according to the appa- 
rent exigency of the case, and they maybe allowed to remain for 
about three or four hours. For extracting them with die least in- 
cimvenienoe, a piece of ivory with a slit is useful, as the oxyda- 
tion of te needles vrhioh takes place causes adhesion and pain 
when they are withdrawn. Adjqpuncture being, according to 

■■■■ ■ I I I ■ I I a I . I H I J I J I I I > ■■ I I a^ I I I ■ I . I 

* The above b oooUary to tbe staUmeati of others, e()aal|y eotitled to credit 
with mynelf. '* Dicam quod mUio" — Cicbro de Orat* As a mechanical meaof 
of leUiog out fluid hi distentioD of dropsical iwetlings, it is oftea of great value. 



264 Dr. Osborne^s Observations on Neuralgia^ 8fC. 

my opinion^ indicated exclusively in neuralgia, and being in it 
a most powerful remedy, which rouses the nerve from incom* 
plete to complete sensation ; its efficacy is greatest when the 
nerves themselves are transfixed in the greatest number. In tic 
douloureux of the face, as the nerves of that part are spread 
over a greater extent of surface than in the fleshy parts of the 
lower extremities, which are the seat of sciatica, it is evident 
that the chance of nerves being transfixed is much less ;. and, 
hence, I think acupuncture will in these cases require to be 
more frequently repeated. The needles which I use in facial 
neuralgia are less than one-half inch in length, and are gene-* 
rally the pointed ends of well-tempered needles broken oflfl 
They must also be inserted in greater number. Not being 
aware of any previous application of accupuncture in tic doulou* 
reux of the face, I now proceed to detail my specimen case, which 
is remarkable, first, for the connexion of the disease with para* 
lysis; second, for the pertinacity with which it resisted all re* 
medies employed during a long time; and, thirdly, the happy 
efiecls which attended the employment of acupuncture. 

Mr. M. aged 36, a grocer, placed himself under my care 
suffering the most acute pain in the side of the face, extending 
under and behind the ear, and shooting into the orbit During 
the last two years the leftside, but during four years previously, 
the right side was the chief seat of pain. His sleep was only 
obtained during short intermissions of pain, which, although 
jiever entirely absent when awake, was yet variable, and at times 
increased to the utmost degree of violence. The mouth was 
slightly drawn upwards to the left side ; the motion of the op- 
•posite side impeded. The tongue slightly protruded towards 
•the left ; the right eye directed inwards from the axis of Tision. 
Within about six months from the commencement of his ill- 
ness, he gradually lost the sight of the right eye, and about the 
same time the hearing of the right ear. His sight had been 
recovered, but in the right ear hearing remained defective, with 
the sensation of a buzzing noise in it. The complaint appeared 



Dr. Osborne's Obiervalions on Neuralgia^ 8fc. 265 

to have been occasioned by untimely cold bathing; a num- 
ber of remedies, including repeated blisters, had been employed 
under the direction of a most judicious practitioner, but without 
benefit. He thought that he once was relieved by the ap* 
plication of ice, but heat although often tried had always failed; 
Having in the first instance cleared the bowels with calomel, 
tartrate of antimony, and senna mixture, I commenced the local 
treatment by rubbing over the affected part the extract of bel- 
ladonna, which was kept constantly applied. Having on former 
occasions seen much relief from this in slight cases of fascial 
neuralgia, it was desirable to see what it could eflbct in this 
case of six years* standing. He experienced no appreciable 
action beyond the prickling sensation it causes on the skin, and 
the dilatation of the pupil. Acupuncture was then practised 
behind the ear, and about the zygomatic arch. It was followed 
by a remission of pain greater than he had hitherto ever ex- 
perienced. Next day the pain behind the ear again began to 
be felt: the needles were applied there in greater number* 
On the following day the pains were reported as fugacious, 
and radier resembling an apprehension of its recurrence than 
pain actually present On several following days he continued 
in this state, but his nights continued sleepless, although free 
from pain. Considering that his want of ^eep was now kept 
up principally by the habit of lymg awake, I gave him acetate 
of morphine, in doses of one-sixth of a grain, in solution, every 
two hours, commencing in the evening. This proving inade- 
quate, he got twenty drops of the black drop. Sleep was at 
once restored. His general health, which had suffered much 
began rapidly to amend. The pulse, previously 116 and hardy- 
fell to 84, and became soft. About four nights afterwards the 
pain re-commenced behind the ear, and further back than when 
acupuncture had been applied. Needles were applied to that 
part, with the effect of completely dislodging the pain. It is 
unnecessary to detail the remedies which were used in the sub- 
VOL. xir. MO. 35. 2 m 



266 Dr. Osborne's Observations on Neuralgia, ^rc* 

sequent treatment of this case^ as the neuralgic pains from this 
time never re-appeared. 

He had afterwards a pain in the forehead and vertex, but 
which was different from the former one, being increased by 
coughing. For this he got pills of calomel and opium tiurioe daily, 
followed by purgatives, an application of leeches to the Schnei- 
deriAn membrane and a sinapism to the nape of the neck, lliis 
pain left him in a short time ; the neuralgic pains no longer 
returned, the result of which was soon visible in a complete 
re^ration of flesh and stroigth. He retained sudi a lively 
sense of gratitude^ on account of his recovery, that he wrote a 
letter to a distinguished individual, who formerly held an malted 
situation in this country, informing him of the new mode of 
cure, urging him to try the same, being influenced by the enro* 
neous, but very common supposition, that all diseases called by 
the same name are to be cured by the same remedies. 

I could cite several other cases, many of them in hospital and 
some in private practice, all showing that stimulation of the nerve 
is the mode by which neuralgic pain is, with most certainty, to be 
subdued. This stimulation of the nerve is most readily effi^Hed 
in sciatica, by a row of needles in the direction of the nerve, 
to which are ancillary rubefacient liniments in the same direc- 
tion, purgatives, quinine in large doses, small doses of turpen* 
tine, a compound of equal parts of Huxham's tincture, and 
ammoniated tincture of guaicum, and freshly prepared carbonate 
of iron, from all of which I have observed benefit There are> 
however, some cases of sciatica in which I have not been oic- 
eessful with the above or with any other remedies, and on a 
strict examination I found the unsuccessfol cases to agree in one 
pdint, that in them the pain along the leg could be excited by 
coughing, the parts being held steady. This appears to me to 
arise from the disease being situated either within the theca 
vertebraliSf or at least in the pelvis, and being thus in ^ i^ftea- 
sure out of tlie reach of remedies. Not that I mean to say that 
such cases are not curable, for I succeeded with aome^ but all 



Dn Lynch's Case of HtmuUuria. 267 

my unsuccessful cases were of this description ; and guided by 
this experience, while I give a promise of relief in the one set 
of cases, I hesitate to do so in the other. It is perhaps unneces* 
sary to add, that there are many cases in which neuralgia is to 
be considered only as a symptom, and dependant on some other 
disease, to which the treatment should be exclusiyely diiiected. 
This has appeared to me so obvious that I have not noticed it 
in the preceding pages. 



Art. XVI.— Ciwe of HcBmaturuu By Martin Hamilton 

Lynch, M. D., of Loughrea. 

— Esquire, aged 37, of a spare form, and temperate ha- 
bits, has never had gonorrhoea, nor has he shewn any symp- 
toms of calculus. About sixteen years since, he laboured under 
disease of the vertebrse, which has left angular curvature in 
the lumbar region. The muscles of the right leg and thigh 
have been wasted, and the movements of the hip and knee joints 
on that side limited from the time that his vertebrae were 
affected. During the sixteen years which intervened between 
the vertebral disease, and the attack to which this communica- 
tion refers, Mr. enjoyed good health. 

About the 6th of August 1836, Mr. — perceived that 
his linen was stained with a puriform urethral discharge ; this 
discharge was not accompanied with any other vesical, renal, 
or urethral symptoms ; the urine was passed in a full stream, 
and without pain. The urethral discharge continued for three 
weeks, it then disappeared, apparently in consequence of the use 
of sulphate of quinine, of which the patient had taken two 

grains thrice daily for a week. Mr. now continued for 

four weeks free from any complaint, if I except an occasional 
pain in the region of the kidney, which he described as " dart- 
ing or stinging." 

Towards the end of September, hsematuria shewed itself, 
the urine was deeply tinged with blood, and after having rested 



268 Dr. Lynch's Case of HcenuUuria. 

for some time^ deposited in the bottom of the vessel a thin 
layer of grumous coagulum ; no coagulum was at any time 

passed from the urethra. Mr. allowed the complaint to 

continue for two. months without having medical assistance; 
during this time he followed his usual occupations, and his diet 
was unchanged, so that there could not have been any very 
urgent constitutional symptoms. At this period, and during the 
few preceding months, he had occasion to apply himself to the 
desk for several hours daily. 

About the 25th of November he was seen by an experienced 
physician, under whose care he remained for some weeks, during 
which blood was taken from the arm, and purgatives were ad- 
ministered; also demulcents, alkalies, uva ursas, the mineral 
acids, &c., without any effect being produced upon the dis- 
ease. 

I first saw him on the 5th of January ; I found the urine 
tinged with blood to the utmost possible degree, but no coagula 
had ever been passed from the urethra ; the grumous deposit 
before alluded to had increased in thickness ; there was some 
debility, and considerable emaciation, his pulse beat eighty, 
and communicated the hsemorrhagic thrill, it was of tolerable 
strength ; his appetite was good ; there was no thirst ; there 
was no irritability of bladder ; pressure made upon the pubic 
region did not give rise to any uneasiness ; the patient slept 
eight or nine hours without emptying his bladder. There was 
not the slightest symptom of calculus ; the urine was passed in 
a full stream ; and the evacuations were so figured as to induce 
me to conclude that there was no enlargement of the prostate 
gland. The urine reddened litmus paper, and exhibited but a 
slight trace of albumen. To the anxious inquiries of the 
patient's family as to the event, I stated, that the affection was 
apparently in one of the kidneys ; that there was no symptom 
which would enable a physician to say positively whether it 
was functional or organic ; and that if organic it would termi- 
nate fatally. I recommended the patient to have eight ounces of 



Dr. Lyncfa*s Case of Htsmaturia. 269 

blood taken by cupping from the loins^ and to take spirits of tur- 
pentine in doses of thirty drops^ four times daily with demulcents. 

Mr. hesitated to submit to this treatment until it had 

been submitted for approval to a distinguished surgeon of 
Dublin^ who having been consulted by letter advised him to 
commence it^ and to take a pint of lime water daily with 
milk. 

The following mixture was ordered and taken regularly 
for nine days. 

1^ Spir. Terebinthinae Rect. 3iii. 

Tinct. Opii gutt. xxx. 

Confect. Amygdalarum 3ii. 

Lactis Amygdalarum, .^vi. M. 
Sumat cochlearia duo majora quater quotidie. 

The lime-water with milk was also used^ and flax seed tea 
drank copiously. 

On the ninth day from the commencement of this treatment, 
the urine was perfectly free from blood, its colour was quite 
natural ; it did not present any trace of albumen on being tested 
by boiling, and the bichloride of mercury ; it changed litmus 
paper to red. The pulse became natural, and all the functions 
were regularly performed. There was a healthy interval of 
twenty-five days, at the end of which the disease returned^ but 
yielded in eight days to the terebinthinate treatment The next 
interval of health was of eighteen days' continuance^ at the ex- 
piration of it the urine was again bloody, but become natural 
after the turpentine had been used ten days. The next interval 
was one of five days^ at the end of which the disease again made 
its appearance, and continued to the time of his going to Dub- 
lin for the purpose of having a consultation on his case^ (7th of 
April.) 

During this new attack, the only additional symptoms were, 

that long, narrow, membrane-like shreds, not of a cylindrical 

form, and similar to moistened cobwebs, were observed to float 



270 Dr. Lynch's Case of Hcematuria. 

in (he urine, and the almost constant presence of severe pain 
shooting from the lumbar region to the umbilicus on each side. 

Mr, made the journey to Dublin, more than eighty 

miles distant from his residence, without hiis disease being per- 
ceptibly aggravated. 

The consultants, three of the most eminent men in Dublin^ 
were of opinion that the bloody urine was produced by organic 
disease, most probably of the kidney, and that recovery was very 
improbable. They carefully examined the state of the prostate, 
and found that there was no enlargement of that gland. The 
directions were that a few ounces of blood should be taken by 
cupping, from the loins, and that the acetate of lead should be 
given according to the following formula : 

Tjt Acet. Flumbi gr. iij. 

Aceti distilhiti 3i* 

Tinct. Opii gutt. iii. 

Aquss dbtill. Ji. 
Fiat haustus 8vis horis aumendus. 

This draught was taken regularly for some days, when the 
occurrence of lead colic, with marked evidence of depressed 
energy of the nervous system, despondency, and tremors, caused 
it to be omitted. 

Mr. was now treated with laxatives, and the muri- 

atcd tincture of iron, for a few days, when lead was again given 
in the following form : 

]gl> Extr. Opii Aquos gr. iii. 

Acet. Plumbi gr. ix. 

Cons. Ros. q. sut fiaut pil. tres. 
Capiat unam mane meridie nocteque. 

But lead again producing disagreeable symptoms, and having 
no effect on the disease, was omitted. The patient left town, 
determined to await the result, without submitting to further 
treatment. 

Mr. reached home on the 20th of April, he now 



Dr. Lynch's Cktse of Hcematuria., 971 

complained much of thirsty he had no desire for food^ his tongue 
was foul, his rest bad, his bowels constipated^ his pulse 120> 
weak^ but thrilling^ his urine was more deeply tinged than ever, 
and the abdominal pains very troublesome. His countenance 
was expressive of great prostration ; the debility and emacia- 
tion were extreme. For some days the patient could not be 
induced to take medicine of any kind ; he xx^x/Ay attempted, but 
in vain, to procure evacuations by the use of " lavements.*' On 
the 23rd, 24th, and 25th, he was annoyed by a most distressing 
hiccup, which disappeared for half an hour, whenever he drank 
a little spring water, or a teaspoonful of vinegar. On the even* 
ing of the 25th he took the following draught : 

T^ Spirit. i£ther« Nttrosi gutt« xxx. 
Camph., gr. iii. 
Confect. Amygdalar. ^ii* 
Mist. Camph. iy. Ft. baustus. 

Also on the same evenmg, three teasponfuls of (he following 
electuary : 

^ Elect. Seimss Jj. 
Elect* .Cass. Fist Jss. 
Supert. Potass. Jiii. Ft. elect. 

On the 26th Uiere was no hiccup, the pulse had fallen to 108, 
and there had been four stools; in other respects the patient's 
state had not improved. 

April 27th. On this day I prevailed upon Mr. to 

submit again to a course of treatment, and I selected alum ibr 
two reasons, first, because it had not hitherto been tried; 
secondly, because the patient still suffered from the deleterious 
effects of lead. I ordered the electuary to be taken at night, 
whenever the state of the bowels required it, and the followin 
draught to be administered thrice daily : 

5, Sulph. Alum, et Pot. gr. xv. 
Acid. Sulph. dilut. gutt. xxx. 
Sulphat. Magnes. 31. 
Inf. Ros. Ji. Ft. haustus. 



O 



272 Dr. Lynches Case of Hcematuria. 

This draught was used regularly to the 15th of May^ when the 
quantity of alum was increased to a scruple in each draught. 
On the 20th the quantity of alum was raised to half a drachm 
for each dose. On the 22nd it was raised to forty -five grains, 
and continued to the 28th. 

During the use of the alum the appetite improved^ the pulse 
fell gradually from 108 to seventy -eight, the rest became unin- 
terrupted, and the bowels were ireed once or twice daily without 
the use of the electuary. After the alum had been given three 
days, the urine exhibited a singular change of colour, it was of 
a deep brown like the strongest porter, and shewed not the 
slightest trace of red, whether viewed in a glass or an earthen* 
ware vessel ; there was deposited from it a yellow powder ; the 
urine presented these appearances for a few days, when it be- 
came the same colour as pale table beer. From this time the 
urine became gradually paler, (except now and then when the 
porter-colour returned for a few hours.) 

On the 5th of May it became perfectly dear and in every 
way natural. The patient has been in perfect health since then, 
except for four or five days in the commencement of June, when 
the urine again became bloody, but this attack quickly yielded 

to the alum given in doses of forty-five grains. Mr. is 

now in better health than he has been for some years. 

Remarks. — This case is one of some interest as exhibiting 
the effects of two of the most powerful remedies in passive 
hsemorrhages, turpentine, and alum. It shews that when an 
haemorrhagic affection has reached the ^^ passive" stage, the 
physician should be extremely cautious in administering lead. 

It is to be observed, that, before the alum had produced any 
effect on the haemorrhagic affection, the symptoms produced by 
the deleterious action of lead had yielded. This case also fur- 
nishes an instance of the administration of alum for several weeks 
in large doses, without the occurrence of constipation, no pur- 
gative being given during that time except the drachm of sul- 
phate of magnesia in each draught. This combination was 



Dr. Beatiy'g Second Report, ^c. 273 

U9dd modt beneficially in a case of hasmaturia^ treated by Mr. 
Guthrie several years ago^^ and published in some of the journals 
of that period. 

It is useful^ with a view to the treatment of other luemor- 
rhageSj to bear in mind the extent to which alum may be given 
without danger of constipation. 

To prove that the remarkable change of the colour of the 
urine to that of strong porter, was not accidental, but depended 
upon the use of alum, I shall relate an experiment performed 
by me in the presence of Mr, Walsh, apothecary of this town. 
I washed the coagulum of blood, drawn about half an hour pre- 
viously from a bronchitic patient of good constitution, in a 
mortar, with eight ounces of distilled water, and strained it Hav- 
ing poured the red fluid, thus separated from the fibrin, into a 
phial, I added a table spoonful of saturated solution of ahim. 
The blood colour changed in one or two minutes to the darkest 
brown, the change being accompanied with considerable effer- 
vescence. 



Art. XVII. — Second Report of the New Lying4n Hospital, 
Dublin. By Thomas Edward Beatty, M.D.,M.R.I.A., 
Consulting Accoucheur, and late Master of the Hospital ; 
Consulting Accoucheur to the City of Dublin Hospital ; 
Lecturer on Midwifery at the Medical School, P&rk-street ; 
and lately Professor of Medical Jurisprudence to the Royal 
College of Surgeons in Ireland. 

The period embraced by the following Report of the practice 
of the new Lying-in Hospital, Dublin, extends from the 1 2th 
of July, 1835, (the date of the former Report, published in the 
Dublin Medical Journal for September, 1835,) to the 31st of 
August, 1837; during which time eight hundred and/our pa- 
tients have been treated^ three of them labouring under uterine 
disease, and eighteen being cases of abortion under four months 

VOL. XII. NO. 35. _ 2 N 



274 



Dr. Beatty's Second Report of the 



of gestation, leaving seven hundred and eighty- three deliveries 
at or near the full time. 

The form of tables adopted in the former Report has been 
followed in the present, as it appears to be sufficiently compre- 
hensive, without being too minute, and it affords a facility in 
summing up the total number of cases treated since the open-^ 
ing of the institution. 

Upwards of sir thousand women and children Iiave been 
prescribed for at the Dispensary attached to the Hospital, and 
three hundred and eighty-four children were vaccinated. 



WOMEN DEUVBRED. 



Naturally, 744 

Artificially, . 9 By r Turning, 

\ Perforator, 

Total, 783 < Forceps, 


1 

1 

7 or 1 in 112 
9 

i OF LABOUR. 


FBBSBNTATIONS. 


DUB ATI OT 


Head ... 743 
Face . . . 2orlin381 
Breech . . . 15orlin 52^ 
Feet ... 9orlin 87 
Arm ... 1 

Funis . . . 4orlinl95TV 

Head and hand 1 

Twin Cases . 8orlm 97^ 


Under 6 houn 
Above 6 . . 

12 . . 

24 . . 

36 . 

48 . 

60 . . 

75 . 


J . . . . 329 
under 12 .274 
. . 24 . 130 
, . . 36 . 31 
. . . 48 . 13 
. . . 60 . 3 
. , . 75 . 2 
. . . 96 . 1 


Total, 783 




Total, 783 


CIIILDRE 


H BORN. 





Males, 414, of whom alive, 374, dead, 40 
Females, 377, . . 354, . 23 



Total, 791 



Total, 728 Total, 63 



New Lying-in Hospital. 275 



TWIN CASES. 



Both children presented head in 6 cases. 
Ist head^ 2nd feet» • • • • 2 

Total, 8 

Of the 63 children bom dead, there were— - 



Footling cases, . • . • 6 

Breech, 10 

Funis, ...... 3 

Twins, 4 

Arm and turning ... 1 

Ruptured uterus • • • 1 

Forceps, 3 



Perforator, 1 

Premature, 9 

Putrid, 8 

Natural, 16 

Acephalous monster . . 1 

Total, ..... 63 



FATE OF CHILDREN IN TWIN CASES. 

Both alive in 6 cases, • • . 12 
Both dead 2 . . . • 4 

Total, 8 Total, 16 

WOBfEN DIED. 

Of puerperal fever, . . 8 

Haemorrhage after delivery, . 1 
Ruptured uterus ... 1 

Total, . . . • lb 

The first point to which I wish to direct attention is, 
the table indicating the duration of labour; in referring to 
which, the number of women, whose labour exceeded twenty- 
four hours, appears to be fifty, or in the proportion of nearly 
one in sixteen. 

My reason for bringing this prominently forward, at present. 



276 Dr. Beatty 's Second Report of the 

18, that since the last Report of the new Lying-in Hospital was 
published, in September, 1835, Professor Hamilton of Edin- 
burgh has favoured the profession with his " Practical Obser- 
vations on various Subjects relating to Midwifery,*' in which 
he devotes a great many pages to the management of the different 
kinds and stages of labour. This work, excellent as it is, and 
coming from the pen of an author, whose great experience, high 
character, and acknowledged talents, entitle him to the respect 
and confidence of the profession, contains some doctrines respect- 
ing the management of labour, from which, with 4he. greatest 
deference tahis opinion, I feel myself called on to express my 
dissent 

In many points relating to the management of difficult la- 
bour, to which I will have occasion to refer, when T come to 
notice that part of the Report, my experience leads me to coincide 
entirely with the learned professor ; but, I regret that I cannot 
equally subscribe to the opinions contained in the following 
passages, relating to the first stage of labour. In speaking of 
that part of the process of parturition. Dr. Hamilton states, at 
P. 188, Part 1 : " He observed that when the natural powers 
are alone trusted to, this stage is often greatly protracted, and 
^ he of course inferred that injurious effects must be the conse- 
quence." What these injurious effects are supposed to be, we 
learn at p. 122. Firstly, " That the powers of the uterus may 
be inadequate to expel the infknt with safety to its life, or to 
the future health of the parent." Secondly, "That after the 
birth of the infant, the uterus may contract irregularly so as to 
occasion retention of the placenta." Thirdly, " That after the 
expulsion of the placenta, the contractions of the uterus may be 
too feeble to prevent fatal hseraorrhagy." And lastly, *' That, 
supposing the patient should escape all those untoward circum- 
stances, febrile or inflammatory affections of a most dangerous 
nature may ensue from the previous protraction of pain, and the 
irregular distribution of blood. 

Acting on the belief that the first stage of labour was thus 



New Lying-in Hospital. 277 

of^n greatly and dangerously protracted, the Professor states, 
p. 19.5 : " From the year 1800 the author has advised hia pupils 
to secure tlie termination of the first stsge of labour within twelve 
or fourteen hours from its actual commencement;" and further, 



278 



Dr. Beatty's Second Report of the 





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Of the nineteen children born dead thirteen were males. 



New Lying-in Hospital. 279. 

Of the eight children born dead under thirty-six hours of 
labour^ one was in a case of convulsions occuring in a first 
labour^ at the end of twenty-five hours, when delivery was 
effected by the forceps-; two were cases of presentation of the 
breech^ attended with much difficulty in passing through the 
pelvis ; one was a case of placenta presentation, one was in a 
case of ruptured uterus, and three were in cases of difficult 
labour, in two of which the delivery was assisted by the forceps* 
Of the four bom dead under forty-eight hours, three were in 
cases of uncomplicated difficult labour, one was delivered by 
the forceps. 

Of the two bom dead under sixty hours, one was a breech 
case, the other a natural presentation. 

The one case bora dead under seventy-two hours was a 
breech presentation. 

The one under eighty-four hours was in a case requiring de- 
livery by the perforator. 

Of the two bora under ninety-six hours, in one case the 
mother was four days in labour before admission — delivery ac- 
complished by the perforator. In the other the labour, though 
constant, was not severe. 

The one case in which the labour lasted 136 hours was ter- 
minated by the perforator. The details of this case were givea 
in the last Report of the Hospital. 

From this table, faithfully extracted from the Hospital book,, 
it appears, that of the sixty-nine women whose labour exceeded 
twenty-four hours^ only one died, No. 38> and her's was a 
case of ruptured uterus; that fifty children were bom alive, 
and nineteen dead, thirteen of whom were males ; and that of 
the nineteen children still bora, one was in a case of convulsions, 
one in a plancenta presentation, one in a case of raptured 
uteras,ybur were breech presentations, three were delivered by 
the perforator, and the remaining nine were ordinary head pre- 
sentations. 

From thb record I think I am justified in sayings that pro** 



280 Dr. Beatty 's Second Report of the 

traction of labour beyond twenty-four hours is' not per te 
productive of those injurious effects described by Dr. Hamilton, 
and that many women may be allowed to go beyond that time 
with safety to themselves and their offspring. I believe there 
are few practitioners in this country whose experience could 
not furnish many instances of labour happily concluded for both 
mother and child at the end of thirty-six or fbrty-eight hours, 
and I make bold to say, that in no country is the mortality 
attending lying-in women less than in Ireland. 

The opinion therefore advanced by Professor Hamilton, 
that the first stage of labour is often greatly protracted when 
the natural powers are alone trusted to, and that when it is, in* 
jurious effects must of course be the consequence, seems to me 
objectionable, because it leads to interference in many cases in 
which it is manifestly unnecessary, and it is calculated to intro- 
duce what has been so well decried by Dr. Blundell, '^ a 
meddlesome midwifery." The effect of such a recommenda- 
tion on the mind of a young and inexperienced practitioner 
must be to induce him to harass his patient by frequent exa- 
minations during the early stage of her labour, a practice which 
is always prejudicial to the patient, by producing excitement 
and irritation in the vagina and os uteri, and thus causing 
what we would desire to avoid, viz., a rigid condition of the 
parts. It is likewise calculated to excite an undue degree of 
restlessness and anxiety on the part of the attendant, and to 
induce him to have recourse to blood-letting, &c. in many cases 
where such proceeding is uncalled for, and by the alarm thus 
produced in his patient's mind, to suspend or materially inter- 
rupt the proper course of labour. Let it not be imagined that 
by the foregoing remarks I wish to dispense with, or undervalue 
blood-letting, opium, &c. in cases demanding their employment. 
What I desire to combat is, the doctrine, that all labours shall 
be reduced to the same limit, and that the period of delivery 
is to be measured out by the clock, allowing a certain number 
of hours to the performance of certain stages of the labour in alt 



New Lying'in Hospital. 281 

cases^ I object to this because I know that the powers of 
endurance are as various as the constitutions of 'patients^ and 
that one woman will bear with impunity a labour under which 
another will sink. Symptoms then, and not time, are the 
guides to which we should look for the regulation of our prac- 
-tice^ and upon that doctrine the treatment of patients in the 
New Lying-in Hospital has been founded ; with what success, 
is now laid before the profession. 

Before quitting this subject I think it right to mention that 
probably there is not so great a difference between the length 
-of time that Dr. Hamilton's patients and those in this city are 
allowed to continue in labour, as he supposes. In this Report 
the labour is dated from the first symptoms, and all suspensions 
are included ; while Dr. Hamilton says, p. 223, Part 1, " It is 
certainly possible that after the first stage is fairly begun it may 
be suspended for some hours, the uterine contractions no longer 
recurring. If during this interval, there be no injurious pressure 
tipon any part of the mother, the previous pains are not to be 
reckoned, but the duration of the first stage is to be dated from 
the recurrence of the pains.'' By following this rule, many 
liours of real labour may be subtracted, and thus a really long 
labour may be made to appear a very short one. For example, 
I attended a lady some years back, who, although recorded 
in my registry as having been twenty -fours in labour, would be 
rated, according to Dr. Hamilton's rule, at half aiv hour, because 
having been seventeen hours in labour, the pains subsided, and 
she bad none for six hours, when a dose of ergot of rye restored 
uterine action, and she was delivered in half an hour afterwards. 
In such a case as this I think it would be unfair to omit all the 
previous suffering in calculating the length of labour, and I 
Allude to it for the purpose of shewing, that the difference in the 
time that Dr. Hamilton's patients and women in this city are 
allowed to remain in labour, may not be so great as he supposes, 
but may be more apparent than real. 
• VOL. xn. NO. 35. . 2 o 



262 Dr. BeaUy's Second Raport of the 

INSTRUMENTAL DE;L1VERIES. 

I now pass to the considerotion of those cases m which it 
appeared necessary to assist the natural efforts of the uterua by 
artificial means. These are eight in nunkber^ seven in which the 
.forceps were employedi and one where it was judged impem- 
tive to use the destructive instruments. 

Before I detail these cases I think it right to state, thsA 
ibougb I have felt it necessary to disagree with the opinions 
advanced by Professor Hamilton on the subject of ordioiirjr 
.labour, it gives me much pleasure to express my entire eonetir^ 
rence in his views and doctrines respecting the mans^ement of 
laborious labours, and it will appear on periiising the history of 
the following eases that the practice pmrsued was just that 89 
ably and clearly recommended by Dr. Hamilton. Nothing 
can be more judicious than the following: '^ On the whole 
it may be concluded, that so long as there are no untowar4 
symptoms in respect to tl^ general health — so long as the 
pains continue to advance the infant — and so long as the pesr 
sages remain in their healthy natural state, the contractions ^f the 
uterus may be expected to complete delivery. But whenever 
symptoms of derangement of the general healthy or evidences 
of the uterine contraction ceasing ta advance the infant, or of 
fhete bein^ an impediment to its advance in consequence of 
some state of the passages, become apparent, and more eqpe* 
cially, whenever circ-umstances denoting injurious pressure, or 
interrupted circulation in the important parts concerned ia 
parturition, occnr, the natural etK>rts can no longer be trusted 
toi"— Page 51, Ptort 2. And again, " The obvious duty of tht 
practitioner in every case must be to Q)scertain what the natupal 
efibrts can accomplish, and when he. is satisfied that the 
delivery can not be permitted to go on without sopf^ injury to 
the mother, or to the in&nt, he is no kmgj^i; tad^^^aWB^EMice; 
keeping this principle in viewj the time allotted for the e^Torts 
of nature must be regulated by the symptoms of the- individual 



Mhw Lying4n Hospital. ^^ 

case." — Page 97, Part 2. With respect to the kind of aid to be 
aflbrded we have the folbwing rational and importiEint observa- 
tions: ^^He considers that after the second stage htt3 tottk" 
menced, if regular pains continue and the infant become 
wedged in the passage, the practitioner is imperiously called 
ypon, supposing the infant to be within reach of the forceps, to 
interfere, before there is a probability that the pressure miiy 
destroy the infant's life, and certainly before any untoward 
symptom threaten the mother. The forceps, if properly applied, 
can do no harm whatever to the motlier> while, by diminishing 
the bulk of Uie infant, it enables the practitioner to lesseti as well 
as shorten her sufferings/' — 'Page 106, Part 2. 

I have said that the practice at the New Lying-in Hospital 
was founded on such principles as these, and I now proceed to 
relate the cases as they occurredi and the result of them. 

Casb I. — ^Bridg^t Boland, aged twenty-five years, first preg^ 
nancy, delivered October 1 0th, 1 835. The head presented in the 
first position, and the labour progressed steadily but slowly,^ so 
that at the end of twenty-four hours, the os uteri Was completely 
dilated, and a portion of the head had passed the brim of the 
pelvis. The pains continued severe and pOnitant, and at the end 
of thirty hours, the greater portion of the bulk of the head had 
passed into tfie cavity of the pelvis, but not so low as to occupy 
^he hollow of t^ saoruili, or make any pressure on the perina^-* 
um. From this time there was no advance in the progress of 
the head, but a tumour began to form on the scalp, whioh he- 
came very large before delivery, and from its bulk was very 
likely to mislead a superficial inquirer as to the adtande of the 
presenting part In this oondition the head remained for sit 
hoviri, notwithstanding frequent and strong pains^ Seeing that 
fhd natural efibrts were apparently unavailing to accomplish 
delivery, the pulse of the woman becoming ir^quent, and a de-^ 
gree of restlessness (whioh is so often tlie precursor of bad symp- 
tonffi) having eome on> and finding by the stethoscope, that the 
child (notwithstanding the pressure it had undergone for thirty- 



284 Dr. Beatty'8 Second Reporr of the 

SIX hours) was still alive, I determined to give it a chance for 
life, and deliver it by the forceps. The instrument was ap* 
plied slowly and cautiously, without using any force that could 
injure either mother or child ; and when the blades were locked, 
the junction lay within the vagina, and the handles pressed upon 
the fourchette ; one blade lay towards the symphisis pubis, the 
other towards the sacrum.* I am thus particular in describing 
the position of the instrument when applied, as it will convey a 
good idea of the part of the pelvis the head was lodged in, and 
the portion of the head that had passed the brim. So far I felt 
certain that no injury had been inflicted on either mother or 
child, and being determined to proceed non vi sed arte, it now 
remained to try whether the amount of force I felt justified in 
using, would be sufficient to extract the head. The blades lay 
one to the pubis, the other to the sacrum, consequently, in the 
direction of these points, lateral motion of the instrument could 
alone be produced. Grasping the handles loosely, so a^ 
not to make too great pressure on the head, I swayed them 
backwards and forwards two or three times during each pain, 
without using much extractive force. By this means, having 
loosened the head in its position, I was enabled to cause 
it to descend slowly at each return of pain, by gently assist* 
ing the uterus ; taking care to apply the force in the direction 
of the axis of that part to the pelvis in which the head was 

* The instrament employed was the short straight forceps, measuriog, total 
length, lOf inches ; length of blade from upper part of the lock, 6f inches ; length 
of handle 4 inches } "widest part between the blades when closed 3 inches; ovt- 
side the blades between the same part ^ inches. 

I think the proportions of Dr. Hamilton's forceps better adapted for g«ieral 
use than the instrument above described ; it is longer, and not so wide between 
the blades. While upon this subject, I wish to mention that many of the forceps 
to be found in the cutler's shops are dangerous to use in consequence of the sharp- 
ness of their edges. Care should be taken that no sharp edge should exist either 
on the outside or in the fenestrum ; the former may injure the mother, the latttt 
may cut'tbe scalp of the infant in the act of extraction* 



New Lying'in UdtpUaX^ 285^ 

placed* Finding a manifest advance^ I was encouraged to per« 
seyere, without being at any time tempted to make use of such 
power as could inflict any injury, and after twenty minutes' pa* 
tient endeavouring, I was gratified by the delivery of a living 
boy, without a fibre of the perinaeum havmg been damaged. In- 
this case, I would have felt myself bound to desist, if I had ex-: 
perlenced any considerable resbtence either in the introduction 
of the instrument or in the attempt at extraction* 

The mother recovered without an unpleasant symptom, and 
\^ the hospital, with her child, at the end of ten days* 

Case II. — ^Mary Brady, aged 24 yean, first pregnancy; 
delivered October 16th 1835. The circumstances of thisoaser 
resembled very much those of the case just detailed, with HtM 
difference, that in the present one, labour was allowed to go on^ 
to forty-eight hours before recourse was had to operation^ 
whereas the last was delivered at the end of thirty-six. The 
reason was that urgent symptoms did not manifest themselves 
so soon as in the former instance. The pulse kept moderate 
until within a few hours of the time at which she was delivered, 
and the os uteri, whidi was very slow in dilating, had not per- 
ioiitted the head to pass through until nearly twenty-four houra 
had elapsed. From that time a slow advance of the head took 
place, but at the end of thirty-six hours not more than . one« 
third of it had passed the brim of the pelvis. In four houra 
more about one-half had been forced through, and from that 
time little progress was made, notwithstanding strong and re« 
gular pains continued* Still, as no unpleasant constitutional 
or local symptoBis were present, I contented myself in watching 
the case, so as to be ready to act as soon as required. The 
patient's strength now began to decline, and her pulse rose to 
110, the vagina at the same time b^an to lose the moist cool 
feel it had hitherto preserved, and to become hot and dry. 
When matten had thus begun to change, I felt that I was no 
longer justified in withholding assistance, and finding the diild 
alive I determined on using the forceps, notwithstanding that 



2S6 Dr. fiefttlj V S§oond lUpmof the 

I could iiot feel the ear^ nor was tfi6 bead near tbe peridHQm*. 
I aocordiogly pooodeded^ in the pretence of Dr. BrcMvn aiMi 
Mr. Armstrong) who happened to Tiiit the hospitid at that 
tioae ;. and I think it right to mention^ that from the lu^ and 
apparently locked position of the head^ both of these geatlemen 
were doubtful of the feucce^s of the operation^ neither was \ 
sanguine myself> and I mentioned to die pupik that it was by; 
no means certain that I would be able to effect delivery in that 
^ay, nevertheless I felt myaelf bound to make the attempt 
under the prudent restrictions as in the last case. ^ a litOe 
management I was enabled to slide the blades of 4ie instrument 
Hp to their proper aitoatiQn, and by degrees assisting the paink 
when they oocurr^i I was enabled to deliver the patient safeljr 
•f a living girh They both left the hospital well on the twdiOi 
day. 

Casi IIL^^WinfVed Meeton^ aged 28 years^ seventh preg^ 
aanby, delivered October IStb, 1^5. This woman bad bcune 
six ebildrenj in tbe ddivery jof which die had always diffioult 
Uibeury and the last diiki was extracted elsewhere by the per-- 
fbrator and crotchet In thid labour^ the bead presented In thft 
first position^ and grOat part of it was foroed throtigh thei brim of 
the ptivi^ whtdi was evidently diminished somewhat in its asN 
t«ro*post^or diameter. A considerable opposition to delivery, 
also, arose in this casei from a oonverg^noe of the spinous pfo-^ 
eelbesoftbeossa ischia^ which encroached upon the cavity of 
tbe pelvis^ and resisted the passage of the head« Finding at the 
ted of twenty-four hours' hard labour, that there was little pros-i 
pcct of delivery by the natural efibrlsi and having tbe fimner 
labours as a guide, I determined not to wait toa long widiont 
atteoBptifig to rescue the child from its perilova sitaation^ if it 
were tooabtsnt with 4he moth^s safety* Acooidingty, tbe for« 
ceps ihv clmtioudy introduced, and as Gautionsly used as an aU> 
tractori and in half an faonr froin the ooramenoement of the ope*^ 
UiOB, a Uving boy was born, who, wi& hw aaotber, eohtiiraed 
tb Ad iweD, uiitil tbey left tbe hospitia on ttie tendi day« ^ ^ 



MfUf Lying4n Hb^gkal. 287 

Ca8» IV.--SaTah Collins, aged 36 years, niiAh pr^iiancy, 
delivered September 30th, 1836. In fliis case, the head pre- 
sented in the fourth position, [NaegeUy) and the labour was very 
severe from the beginning. At the end of twenty hours, the 
head was firmly fixed in the pelvis, with the anterior fontanelle 
towards the pubfs, and in six hours more, finding that no advance 
had taken place^ and the vagina was becoming tender to the 
touch, vehile the pulse was gradually increasing in frequency, 
Ae delivery was effected by the forceps, the child being dead. 
'This patient made a good recovery. 

Cask V. — ^This was the only instance in which I ever knew It 
necessary to assist the delivery of the head in a breech or footling 
xase, by instrumental aid. Catherine Connor, aged 30 years, de- 
livered November 1 2th, 1835. The child presented by the feet, 
and the labour went on without any remarkable circumstance, un"- 
til the arms had been got down after the expulsion of the breech^ 
when great difficulty was found in the passage of the head. 
This was not owing to any improper force used in pulling at the 
body of the child, for \ happened to be in the ward at the tune of 
delivery, and superintended the management of the case myself. 
The labour pains continued strong, and the cord pulsated for a 
considerable time, during our endeavours to extricate the head. 
But in all fny attempts to accomplish it I fidled, and at last, 
after nmre thatt half an faour^ finding ihd oircuhtioD in the funis 
beeasM weak, I determinad on using the foroepn. Unfectit» 
nately the imrtrooMnt was not in Aie hospital^ and I had to send 
to my own botne (a very dwrt diatanee) bt it; this caused ft 
trUing delay, whioh,. baneyer, was fatal to tfaa H^t^ for b^ofo 
ibe aMssenger letamed^pobatioii bad entirely oeaaed. I p^taad 
the blades along the sides of the head, having tbo bodf df tbt 
iBfimt carried forwaid belwe«D the Ibigks of this mother, and 
v^baome diffienlty I succaeded ia eastnietkp« tina head Wp 
tried all meana to fewiagit«le;tfatt iofcttt wifcou* snocws. 

Case VI.— A case of convulsions, to be det»kd in aM^ber 
part of the Report 



288 Mr. Beatty's Second Report of the 

Casb VIL— Delivery was accomplished in diis case in conse- 
quence of rupture of the uterus^ und» which head it will be 
found. 

DELIVERY BY THE PERFORATOR. 

r 

Case L — Rose Aidy, aged 27 years; first pregnancy^ de- 
livered March 19th, 1837. This patient was admitted on the 
16th, having had pains for two days previously. She was of 
low stature, and in external configuration corresponding with 
the description I gave in the former Report, as one indicating a 
difficult labour, viz.: ''Alow, thickset, brawny frame, with 
broad shoulders and thick limb^ short stumpy fingers as if 
the last joint of each was cut off, v^ rigid muscular fibre, 
and nates so large as to render examination per vaginam 
difficult'' On admission the pains were slight, the os uteri 
dilated to the size of a sixpence, with sharp and thin edge* 
The abdomen very prominent and conical, pulse 80. 

17th. Had some sleep, the pains regular, but not severe; 
pulse^ 80; os uteri dilated to the size of a shilling, still 
▼ery rigid and sharp. 

V.S.ad.3ivj. 
1^ AnU Tart. gr. ij. ■) 

Aq. foot. |viij. sumat cochL i. amp. onuu bora* 

18th. No further dilatation of the os uteri. She com^ 
plains of soreness of the vagina on examination. Tlie bowdb not 
having been freed, two purgative enemata were administered. 
Ten o'clock p.m., pains stronger, os uteri of the size of a half 
crown, the edges thicker, but very rigid, no advance of the 
head. An enema with tinct opii gutt. xl. was administered^ 
trhich was fi^)eedily rejected. 

19di. Had some sleep, pains more frequent and sevelfe. 
The waters were discharged spontaneously during the night. Ov 
uteri not more dilated, complains of soreness: of the: belly on 
pressme {.pulse 84^ . ' 



New Lifing-in HotpiUd. 269 

V. S. ad. jxsi?. 

Haust. c. tinct. opii. gutt. xxx. 

The foetal heart was heard at the right side below the 
umbilicus. Four o'clock p. m. ; has had no pains since twelve 
o'clock, has slept some, and passed water, os uteri a little more 
dilated, and the infant's head more forced into the brim of the 
pel\ris ; a tumour of the scalp projects through the os uteri ; pulse 
92. Nine o'clock p. m. ; strong and frequent pains since last report, 
OS uteri dilated. The tumour on the head very l€U*ge, and the 
right parietal bone overlaps the left considerably, but there 
is no advance of the bulk of the head through the brim of 
the pelvis. Blood trickling from the vagina, and the discharge 
fbetid. She has vomited repeatedly a dark-coloured fluid dur- 
ing the last few hours, and there is great tenderness of the belly ; 
pulse 120. Considering these symptoms, and that she was now 
eighty-two hours in labour since her admission, I judged it not 
safe to allow her to pass another night without being delivered^ 
and the head being quite beyond the reach of the forceps, I 
was obliged to have recourse to the perforator. Great difficulty 
was experienced in getting the head through the pelvis after 
its contents had been discharged, and nearly an hour was occu- 
pied in the delivery. In half an hour after the operation the 
patient's pulse bad fallen to 104, and she was left with direc- 
tions to have an anodyne draught, if restless. 

20th. She slept wdl without opium, has no pain in the 
abdomen, passed water freely this morning. Pulse eighty. 
Bowels confined : to have Ol. Ricini Jj. 

This patient had no unpleasant symptom afterwards, and 
recovered as well, and as speedily, as the other women in her ward. 

On reviewing these cases it will appear, that of the seven 
cases of ddtyery by the forceps, four of them were head pre- 
sentations in uncomplicated labour, in three of which, the child 
was saved ; two of these being first pregnandes. In the other 
cases of head presentation, complications arose which usually 
produce the death of the fcetus, and in the footling case the loss 
VOL. XII. NO. 35. 2 P 



290 Dr. Beatty's Second RfipoH of t/ie 

of the infant must be attributed to tbe unfortunate delay in 
procuring the instruments. 

It may be objected to tbe practice above detailed, that in 
the first four cases delivery might have been accomplished by 
the natural eflTorts, and therefore instrumental aid was nol 
necessary. True^ delivery might have been accompliAedy but 
I would ask at what risk would the experiment of waiting be 
made ? Urgent symptoms of local and general irritation had 
manifested themselves in all^ before any attempt was made to 
assist tbe uterine effort^ and the head of the infant was arrested 
in such a position as precluded the hope that it eould be passed 
through (if at all) without several hours' severe labour, and a cor- 
responding increase in the dangerous symptoms, which must 
have arisen to such a height before delivery, as would place thpi 
woman's life in immediate danger, and her future comfort in 
considerable jeopardy ; besides in all probability destroying 
the life of the child. From this state of peril the women were 
rescued, and three of the children were bom alive, which, undet 
other treatment, must have been sacrified. They were, I aay^ 
rescued by a safe operation, and they recovered as well as if 
their labour had been natural and easy. 

With respect to laceration and sloughing of the vagina^ 
bladder, &c., stated by «ome authors to be pauaed by tbe 
forceps, and used as an argument against their employment, I 
am of opinion that in the majority of cases, when these, la^ 
mentable results occur, the blame is unmerited; because I 
have seen the worst inflammation and slou^ngs of theaa 
parts follow in cases where the perforator had been used, 
and even in some where no instrument whatever was eo^ 
ployed. The truth is, the mischief is effected by tbe pressure 
of the infant's head upon the soft parts of tbe mother, and 
after this has been continued with sufficient intensity, for a 
sufficient length of time, tbe inflammation caused thereby will 
run its course, no matter in what way delivery is accom^ished^ 
whether by the natiu«l effi^rts, or by instruments. But it 



JVetr Lying4ft Hospital. 291 

frequently happens that delivery is effected in these cases by 
instruments, too late to prevent the unhappy results alluded to, 
and then the operation is charged with the consequences. If 
an accurate account of the subsequent condition of ail women 
after delivery could be obtained, I much fear that the histo- 
ries of those cases in which labour had been allowed to run 
too long before interference was used, would be anything but 
satisfactory. The lamentable sloughings of the vagina, with 
subsequent closure of the passage by the process of cicatriza- 
tion j or the still more distressing sloughing of the bladder with 
its attendant urinary fistula, are seldom mentioned in lying-in 
hospital reports, because tlie patients are usually removed 
from those institutions before such results have become very 
apparent ; and thus, a case left to nature, in which delivery is 
effected by the natural efforts, is set down as a favouraUe one, 
without any notice of its consequences. 

That injury may have been effected by unwarrantable 
roughness in the use of the forceps, or by ill made instruments, 
I admit, but that injury is even likely to result from the use of 
this instrument, when judiciously employed, I entirely deny. I 
have seen a surgeon, in performing the operation of lithotomy, 
force his forceps through an imperfect opening into the bladder, . 
and then, having grasped the stone, finding that he could not 
extract it by ordinary force, place his foot upon the cross bar of 
the table, and pull with all his might, and nearly fall on his 
back, when the stone came out with a jerk. I have known the 
patient to die after such a proceeding ; but am I on that account 
to decry the operation, and deny its saving powers, when the 
instruments are in the hand of a skilful and dexterous surgeon ? 
By no means ; I charge the blame where it is due, I decryr the 
bungler ; but my faith remains unshaken in the operation, when 
conducted upon rational and scientific grounds. Whence then 
proceed the local injuries to which I have alluded ? manifestly 
from delay, after urgent symptoms have set in. This opinion 
is not advanoed for the purpose of recommending rash or hasty 



292 Dr. Bca^y*s Second Report of the 

interference in all cases ; (the table of prolonged labour already 
given shews that such is not my practice) ; but it is with the 
view of inculcating the obligation to watch our cases closely, 
and to interfere when necessary, and only then. 

ITiis point of necessity is the great question in dispute be- 
tween practitioners, and I trust there are few at the present day 
willing to follow the directions of Dr. Osborne, " to wait till the 
powers of nature are absolutely or altogether exhausted,** when, 
as it has been said by the late Dr. Beatty, " our interference 
can only remove a dead child from a dying mother." On the 
the contrary, I am happy to believe that the prejudice so long 
existing against the timely use of the forceps is subsiding, and 
that many practitioners will agree with Dr. Hamilton, *' that the 
great utility of this mechanical contrivance is, that it enables the 
practitioner to prevent the occurrence of those untoward symp- 
toms, which Dr. Osborne has described as alone warranting the 
use of the instrument." 

CONVULSIONS* 

Mary Nolan, aged 20 years, of a full, plethoric habit, first 
pregnancy, admitted December 20th, 1836. 

On admission the os uteri was dilated to the size of a half- 
crown piece, and the pains were regular and efficient Labour 
progressed steadily, and at the end of four hours the dilatation 
of the OS uteri was nearly complete, soon after which the head 
began to advance into the pelvis, and at the end of six hours 
the greater portion of it had passed the brim, and nearly filled 
the hollow of the sacrum. The pains continued to recur with 
conuderable violence, vnthout making much impression on the 
position of the head, and the external parts being rigid and dry^ 
she was bled to |xiv. This had the effect of relaxing the 
vagina and perin»um, but at the expiration of twenty-foui^ 
hours, the head, although lower in the pelvis, and moving at 
each pain, had not yet come to press strongly on the perinsBum. 
In four hours more, (twenty-eight from admission), there vnu 



New Lyxng^m HospiUdi 293 

no untoward symptom calling for interference^ the pulse was 
eighty^ the pains regular, and the head manifestly advancing, 
when she was suddenly seized with a violent convulsion. Deli- 
very by the forceps was immediately had recourse to, and much 
difficulty was experienced in the operation, owing to the unma- 
nageable state of the woman, and the great size of the infant's 
head, which was found to measure four inches between the 
parietal protuberances. The child was dead.. The delivery was 
accomplished at one o'clock, a. m. of the 21st From that time 
she had four convulsions, diminishing in severity through the 
night, but towards morning she sank into a comatose state, from 
which slie could be roused, not however to consciousness, but to 
mania, her face being flushed, her eyes starting, the pupils con- 
tracted, and she resisted with violence any attempt to administer 
medicine by the mouth. She did not speak, and when al- 
lowed to remain undisturbed, her breathing was stertorous, ac- 
companied by a hissing noise in expiration. 

21s^ Eight o'clock, a. m. Finding the above-mentioned 
symptoms to have set in and her pulse 140, she was bled to 
^xxiv; and in a few hours the bleeding was repeated to |xxx. 
as the former abstraction had produced no relief. The blood 
drawn on both occasions was highly buffed and cupped; has 
bad noiconvulsi6n|through the day. 

Six o'clock, p. M. The breathing less laborious; pulse 
130 ; her^head was shaved and cold lotion applied. 

22nd. Spent a restless night; comatose symptoms still con- 
tinue, but the£violence of the mania is somewhat abated. A 
bolus of calomel andjjalap was got into her mouth, which she 
8wallowed,^dj an enema with spirit terebinthin® having been 
administered in four hours afterwards, the bowels were well 
freed. 

Six^o'dock, p. M. Symptoms as before. 

V. S. .^xviii., and a blister was iqpplied to the head. 

23rd. Passed another Restless night, the urgent symptoms 



294 Dr. Beatify Second Report of the 

of coma rather less^ but she is still quite insensible to ques- 
tions put to her ; pulse, 130. Ordered a repetition of the 
bleeding to sixteen ounces, and a blister between the shoul- 
ders. 

Six o'clock, P.M. The symptoms have yielded since last 
report, she can now answer yes and no, there is not much ster* 
tor in her breathing, and her pulse has &llen to 118, and is 
soft ; she passes faeces and urine involuntarily. 

24th. She had some quiet sleep during the nig^t, and is 
more collected this morning ; complains of the blister on her 
back ; takes her drink ; puke 100. 

From this time she continued to improve gradually, bat die 
bad no recollection of any part of her labour. 

RUPTURED UTERUS. 

Anne Gaynor, aged 27 years, ah extern patient living in 
Purdon-street ; fifth pregnancy, March 11th, 1837. Labour 
eommenced at seven o'clock in the evening, the waters were 
soon discharged spontaneously, and the head came down into 
the pelvis in two hours. The pulse was a little excited, and 
the countenance florid, the vagina rather dry, but cool. The 
pains continued smart but inefiectual, communicating very slight 
impulse to the infant's head, and rectoirring every ten minutes. 
The patient was very restless, getting out of bed occasionally 
and walking about, and when in bed she was continually chang- 
ing her position. At eleven o'clock there was a discharge of 
about four or five ounces of blood firom the vagina, but there 
was nothing remarkable in the paia immediately preceding the 
occurrence. Shortly after, however, her pulse begmi to alter 
in character, becoming smaller and quicker ; her oomplexi<m 
began to fade, and the pains, in the same gradual manner, de- 
clined in degree, but not in frequency, for about two hours, 
when they ceased entirely. About this time she begao to com- 
plain of pain in the epigastrium, where the fundus uteri pro- 



New Lying-in HofipikU4 295 

jected in a remarkably prominent manner. A soft diffused 
swelling appeared above the pubis^ which continued to ascend 
slowly towards the umbilicus^ and expand laterally^ masking the 
uterus as it advanced, by intervening between it and the parietes 
of the abdomen. Vomiting now set in^ and intense thirst, to 
relieve which she drank large quantities of cold water, but im- 
mediately rejected each draught. The sinking of countenance, 
depression of strength, resdessness, and anxiety, progressed very 
gradually but steadily from thi^ period, until the pupils in 
charge of the case (who had neglected to send for assistance to 
the hospital when alarming symptoms had set in,) reported the 
condition of the woman. On visiting her she was found to be 
moribund, the pulse imperceptible, and the extremities cold. 
The head of the infant being still in the pelvis, it was delivered 
by the forceps, immediately after which the woman expired. 

On introducing the hand, a large laceration was found at the 
neck of the uterus, immediately in the neighbourhood of the 
promontory of the sacrum, which was unusually prominent and 
sharp ; and, on passing the hand through the rent, a large quan- 
tity of coagulated blood was found in the abdomen among the 
intestines. Leave could not be obtained to make any further 
examination of the body. 

In this case it is manifest, from the sjrmptoms, that death 
was ^e consequence of haemorrhage into the cavity of the peri- 
tonseum. This mode of termination might possibly have been 
avoided, if timely notice had been given; but the woman, if 
saved from death from diis cause, would still have had to en- 
counter the usual danger of peritonasal inflammation. It is to 
be remarked, that two symptoms mentioned in books, and often 
present in cases of ruptured uterus, did not accompany the in- 
stance just detailed : namely, a sudden pain and sensation as of 
something having given way within the patient, and a receding 
of the presenting parts. The latter was prevented by the low 
position the head had reached in the pelvis before the laceration 
took place. The unusual prominence and sharpness of the 



296 Dr. Beatty's Second Report of tlie 

promontory of the sacrum^ fumUh an explanation oF the readi- 
ness with which rupture took place in the case before us* For, 
the woman having previously borne children, it is easy to con- 
ceive how the neck of the uterus must have been compressed 
against this sharp ridge^ whereby an amount of inflammation, 
capable of altering its texture^ would have been excited, which 
would render the part thus diseased unable to bear the disten- 
tion attendant upon a subsequent labour. 

RETAINED PLACENTA, FATAL HJEMORRHAGB. 

Mary Brophy, an extern patient, living in Fleming^s-plmoe ; 
sixth pregnancy, aged thirty years, October 6th, 1836. This 
woman was delivered at eight o'clock in the morning, after an 
easy labour of twelve hours' duration. The placenta was retained 
until twelve o'clock, when I was summoned to her aid. A con- 
tinued draining of blood had been going on from the time of 
delivery, but not being at any time very great, her attendants 
were deceived as to its danger* I found her in an extreme 
degree of exhaustion from loss of blood, her pulse imperceptible, 
extremities cold, countenance pallid, and great restlessness, with 
jactitation. She complained of oppression of breathing, and of 
noise of carts rattling in her ear. Strong spirituous stimulants 
were now administered, and I passed my hand into the uterus, 
where I found the placenta partially adhering, and the remainder 
detached from the uterus. I removed it and a large quantity 
of coagulated blood at the same time, and the uterus was made 
to contract by friction and strong pressure over the pubis, in 
which state it was firmly bound down by a broad bandage and 
compress. Opium, and stimulants, with friction of the limbs 
with warm flannek, were now liberally employed, but without 
the effect of rallying the patient The haemorrhage was quite 
arrested, but the constitution seemed to have received too great 
a shock from the previous loss, to be able to recover, and the 
woman sank by degrees, and finally expired three hours after the 
removal of the placenta, and seven from the time of delivery* 



New Lying-in Hospital. 297 

This case is an example of die insidious and dangerous 
nature of that form of hsemorrhage^ in which there is no consider- 
able outburst of blood at any one time, but the inexperienced 
attendant is lulled into security, by the apparently small quan- 
tity of blood the patient is losing, not considering that, though 
small at any one period, yet when allowed to go on for a length 
of time, the aggregate becomes a serious quantity, and thus the 
patient's life is run into the greatest danger before alarm is 
taken. 

FUSRPERAL FBVBR. 

The hospital was visited by this terrible malady twice, dur- 
ing the period embraced by the present Report. Both attacks 
took place in the month of January, and at each time erisypelas 
was raging as an epidemic in the surgical hospitals, and diseases 
of a typhoid type were rery prevalent in this city. 

The first case about to be related, is one, which, under otlier 
circumstances, might be considered as not being entitled to the 
name of puerperal fever, because tlie organs principally afiected 
were not those in which lesion is usually found in this disease, 
but from its being tlie first case that occurred at that period, 
from the typhoid symptoms by which it was attended, and from 
the severity of the disease in the other women, who were imme- 
diately attacked in the same ward, I have little hesitation in 
ascribing it to the same influence that produces the better 
marked puerperal fever, although the local aflTeotions in this case 
were different from what are usually present. 

Case I. — Anne Early, aged 22 years, first pregnancy, deli- 
vered January 30th, 1836, of a living child, after nine hours of 
labour ; continued well the next day. 

February 1st. Complains of acute pain in the left side, under 
the breast, and extending to the back, which prevents her 
making a full inspiration, and produces a good deal of dyspnoea. 
There is some tenderness over the uterus increased on pressure; 
countenance flushed, pulse 130, small. She was bled to sixteen 
ounc^, cupped on the side, and ordered a laxative draught. 

VOL. xu. NO. 35. 2 Q 



^98 Dr. BeaUy*8 Second BepaHof the 

Ten d*clod(, p. m. No relieE Brea&kig forty in the minute ; 
dy$pn<Ba increased; pulse 140. ExMxiination with the ste&o- 
scope indicated intense bronchitis in both lungs. 

Repr. y. S. ad j^xvj. 
A pill of calomel gr. ij., and opium ^ gr. to be taken eyery two boors. 

2nd. Had profuse perspiration during the night, which s^ill 
'continues ; symptoms as before ; slight cough, but no expectpra- 
tioti. Tenderness of the belly continues. The calomel was in- 
creased to 3 grains, and opium to \ grain every two hours. 

Ten o'clock, p. m. Breathing easier, feels less oppressed^ 
countenance pale ; pulse 130. No appearance of si^vlitibn: 

Contr. piL A blister to both sides. 

3td« Slept none ; breathing laboured ; great exhaustion ; coun- 
tenance sunk ; pulse 13(^ weak and small ; no expectoration ; in- 
tense muco-cre{Ntating rale all over the chest on both sides. 
BeDy more distended and tender. Ordered an emetic of ipeca- 
cuan and tart, emetic. 

Four o'clock, p. m. Great distress in breathing. Pectoral 
sounds less audible, chest sounds dull on percussion ; pulse 
scarcely perceptible. 

]go Ammon. Carb. gss. 
Mist. Camph. ^vL 
Sumat ji. omni hord. 

From this time she continued to sink, and died early on the 
morning of the 4th. 

Post mortem, A copious effusion of sero purulent fluid was 
found in both sides of the chest. The fluid resembled closely 
that usually found in the peritoneum in cases of puerperal feyer. 
Patches of lymph adhered in different places to the serous 
membrane. The lungs were compressed, dark-coloured, but 
not hepatized, and when cut into, they gave out a large quan- 
tity of frothy sero purulent fluid. There was a small quantity of 
fluid in the pericardium. The peritoneum exhibited vascula- 
rity in different places, but there was no effusion of lymph or 
fluid into its cavily, neither were there any adhesions. 



JSIbw Lying-in Hospital. 299 

' Case I L— Jane Beatty) aged 22 yeArs^ second pregnancy^ 
delivered at seven o'clock^ p. m., Febrnary 2nd9 1836. 

This woman lay in the bed opposite toher^s whose case has 
just been d|^iled. A few hours after delivery she had a rigor, 
and. soon complained of severe pain in the belty, accompanied 
by vomiting, pulse 1 10. She was leeched freely, and fomented 
over the belly, ^nd an emdHient enema was administered. 

3rd. Nine o'clock, ▲. m» Belly tympanitic ; severe pain j^ 
vomiting continues; countenance muddy and sunken ; pulse 104| 
weak. Gave her an ounce of iq^irit of turpentine, which was 
soon rejected. 

Turpentine fbmention to the beUy. > 

Pills of calomel aad opium Soda q* q. hor&* 

' Four o'clock, p. m. All symptoms worse. 

Ten o'clock, p. m. Evidently sinking ; poise imperceptible ; 
feet cold ; vomiting continues. 

' 4th. At seven o'clock, a. m. she died, just thirty*six hours 
from the time of delivery. 

^ P. M. seven haur^ after Death. — ^tlie tymponitb of the 
belly had subsided, and the uterus could be felt as high as the 
umbilicus. On opening tfie abdomen Ae peritoneum lining 
its walls> and covering the viscera, was found minutely injected 
with red vessels in every part, but particularly over the i^rus, 
fiillopian tubes, and ovaries. There was a small quantity of 
thin, uniform, reddish-coloured, serous fluid in the odvity, but 
ito lymph. An incision in the long axis of the uterus dis« 
played its walls of great thickness, and its inner surftce was of 
a deep chocolate colour, particularly in the cervix and neighs 
bouring part of the vagina^ A small quantity of jMrum existed 
in the pericardium, but there was no tmoe of diseose in the 
pleurae. 

Casb III. — Margaret Mooney, aged 29 years ; fourth preg- 
nancy, delivered February 2nd, 1836. 

In this case the infant presented with the breeoh, and was 
bom alive, after a labour of three hours. 



300 Dr. Beatty 'a Second Report of the 

4th. Ten o'clock, a- m. Had a shivering fit in tlie night, 
complains pf pain in the belly, increased on pressure^ great thirst; 
countenance sallow; pulse 120. 

V.S.ad.Jxyi. l«* 

Leeches to the ahdomeny with fomentation^ calomel and opium every 

second hour. 

Ten o'clock, p. m. Belly tympanitic ; pain severe ; counte- 
nance sunk ; pulse 130. Continue the pills, two drachms of 
mercurial ointment to be rubbed into the belly. 

5th. Slept well ; pain and tenderness of the belly as before; 
lies on her back; has not passed water for several hours: a 
catheter was introduced which gave exit to some turbid, high- 
coloured urine. Continue the pills and ointment 

Ten o'clock, p. m. Belly not so much swollen, passes feces 
involuntarily ; pulse 128. Sleeps a great deal. 

6th.|Belly more tympanitic ; pulse 140, weak; countenance 
greatly sunk. Contmue pills, with a mixture of carbonate of 
ammonia. 

She continued to sink, and expired at seven o'clock, p. m. 

CasesIVT. and V Julia CahiU, andElizabeth Kelly. These 

two patients were delivered in a ward distant from that occupied 
by the last three, at one o'clock, a. m., February 5th. They 
both shivered in the evening of that day, and soon were attacked 
with pain in the belly. Cahill, who was a strong, plethoric 
woman, was bled to Jxvj. Kelly being weak, thin and pale^ 
was not bled, except by leeches to the belly. The disease ran 
a somewhat longer course than in the other women who died. 
Cahill died on the 8th, and Kelly lived to the 9th. They had 
both very early exhibited the sallow, muddy, sunken counte- 
nance, a symptom which I have always found to forebode a fatal 
termination. No post mortem examination was made of these 
women. 

Three other patients were attacked with alarming symptoms, 
which yielded to treatment similar to that just mentioned in the 
other cases. 



Nbw Lffing-in Ofipilal. 301 

Tbe hospital was' now closed against any furtlier admisdons. 
FBtienU who were sufficiently con¥ale8cent after delirery were 
sent bome, and the walls were thoroughly cleansed, painted, and 
white-naslied, after being exposed to the vapours of chlorine 
for two days. The admiasioa of patients was resumed in a fort- 
night, and no new case of the disease appeared for twelve 
moolbs, when in the month of January, 1837, a fredi hurst of 



302 Dr. Beatiy*a Second Repori of the 

Ae skin on tie face, neck, and chert, is dingy; piil«e 140, 
feeble ; belly tympwiitic- Ordered tinct opii with aramatic 
oooTection, and camphor mixture. She oontinned la siek, and 
(&d at ten o'eloQk, p. M. 

On exambatioa after death, oonriderable effuskm of sevo* 
pnhilent fluid was found in both sides of the diest, and the 
lungs contained the frothy floid characteristic of tiie last rtaga 
of bronchitis. . In the abdomen the peritoneum was wiy vascu- 
lar, and the same kind of fluid as in the chest wasfeund efl[used. 
Patches of lymph cov«^ the intestines, ind were numeibus 
ab<rat the pelvic viscenu 

Case VIL — ^Alica Kavenagh, aged tfairty-linree years, de« 
lirered of her fourth child, after a labour of fourteen hours^ ifetme 
day as last case. This was a poor, wretohed-lookkig, dejected 
creature, confined in the same ward with Piniay. She was at- 
tadLed on ihe second day after deliverf with shivering; to wiHch 
speedily succeeded acute pain in the utaine r^ion* Pulse 120| 
small and weaL 

Her whole conditioa oontra^indicated general blood-letting* 
Lseches were implied to the abdoaoen, and repeated in six 
hours. Fomentations were used diligently, and she was ordered 
ci^mel with opium every second hour. The disease assumed 
the typhoid type from the first in this pati^st ; she soon put on 
the -leaden hue. of countenance, resembling that observed in 
cholera so strongly, that those who saw her were immediately 
struck by it. The symptoms progressed in spite of dl measures 
used to arrest them, and ^ died on the 12th, the fourth day 
after the seinire. 

Case YIIL — Sophia Cameron, aged twenty-one years, de« 
Uvered of her second child, January 10th, 1837, after five hours^ 
labour. 

This patient came into the hospital under peculiar mental 
depression. She was attacked on the second day after delivery 
with severe pain in the belly, which soon occupied the entire 
oegion, and idie could not bear the slightest pressure in mf 



New £yu^-m Holpitai. S(^ 

part. Pulse 120. She was bled to Jxri, and lefich^ fr»«put 
on over the whole abdomen. She got a draught of six drachm* 
of caator oil, with the aarae of apirils of turpentine, which was 
«oon rejected by romitlng. Intenae thiret harassed her, And 
whatever she drank was speedily ejected. Calomel flod opium, 
with mercurial Grictionp, were freely employed, but without 
eSect. She becaine detirioua on the third day of the attack ; 



304 Dr. Be£iitj*s Second Heportcfthe 

to conclude that the infection was conveyed to her by her at- 
tendants. 

It is not usual to believe that persons not puerperal can be 
influenced by the disease under consideration ; but three cases 
occurred during the former epidemic, which afford some grondsu 
for thinking that such may be the case. The two nurses who 
were engaged about the sick> were both attacked with a low 
form of fever^ in which great prostration of ^strength was a pro- 
minent symptom, and from which they recovered very slowly. 
The unusual exertions and watching which they were called 
upon to use at the time, might, no doubt, have contributed to 
produce fever, but it seems at all events, a coincidence worthy 
of remark. The other case was one which had been under 
treatment for a considerable time in the Hospital, in conse- 
quence of 

PABALYSTS AFTER DELIVERY. 

Anne Kiemaa, aged 21 years, delivered of her first child j 
November 26th, 1836, after a labour of seven hours ; infant 
alive.- Nothing remarkable occurred during lab<Hir, or afterr 
wards, until she complained on the second day, that she could 
not move her right leg, and that it felt benumbed and dead. 
On examining the limb, no swelling or pain could be disco- 
vered at any part that could indicate the approach of phlegma- 
fiia dolens ; on the contrary, the sensibility of the limb appeared 
considerably lessened. 

Frictions, with warm turpentine, were ordered to the limb^ 
but without any effect upon the condition of the part At the 
end of a fortnight, finding that no improvement had taken placp, 
a course of blisters along the line of the sciatic nerve was com- 
menced, beginning above, and gomg downwards. This plan, 
together with attention to her general health, had the effect of 
gradually restoring the power of the limb-. In a month she was 
able to walk across the ward with the assistance of a stick, but 
even yet the leg was jdragged along with difficulty, and when 



New Lying-in Hospital. 303 

carried fornard, the foat hung looie and vaccilating, tbe toes 
pointing to the grouDd. In another month she had regained 
considetahle power over the muscles, her progression was 
much more firm and steady, and the seDsibility of the limb 
was almost entirely restored. She continued .to improve until 



306 Dr. Beatty's Second Report of the 

formed at the time, that they were all the result of exposure to 
the noxious influence of puerperal fever. 

AC£PHALOUS MONSTER. 

January 20th, 1837. Mary Maguire, aged 25 years, haying 
come to town for advice, was sent to me by a professional friend 
for my opinion. She states that she 19 a widow^ her husband 
having died seven months ago, that she was married two years, 
and had no cliild, and that the menses have been suppressed 
ever since the death of her husband. In consequence of this 
symptom she bad been supposed to labour under amenorrhcea^ 
and had been subjected to active treatment in the country for its 
removal. By degrees her abdomen began to 9well, and her 
feet and legs became oedematous. Dropsy was now supposed 
to be her disease, and the usual remedies were had recourse to, 
with no sparing hand. Finding that notwithstanding all slie 
had gone through, the increase in size still continued, she de- 
termined to come to town for advice. 

A glance at the woman's countenance told me that she was 
not labouriog. under any serious disease, for although she had 
nm the gauntlet of repeated bloodletting, mercury, purgatives, 
and diuretics, she still. retained a glow of health in her cheeks 
quite inconsistent with a grave malady. Tliis I may remark i^ 
a circumstance not to be overlooked in judging of obscure cases 
of pregnancy, when, from ignorance or design, the attendant is 
likely to be deceived by the statements of the patient 

Her abdomen was very large, and on examining in the re- 
cumbent posture, I found a large tumour rising from the pelvis, 
as high as the umbilicus, uniform in its surface, and of a 
globular shape. On applying the stethoscope a faint souffle 
was heard at the lower part on the left side, and a very indis^ 
tinct pulsation of the foetal heart was distinguished at the right. 
On passing the finger intp the vagina, the cervix uteri was found 
.diminished in length and softened, and inspection of the breasts 
disclpsed well marked areolae, studded with prominent emi- 



New Lying-in HpspilaL 307 

nences. From these symptoms I had no hesitation in decla- 
ring her to be seven months pregnant, and I advised her to 
return to the country until the time of delivery drew near, 
but to take no medicine except some laxative pills with which 
she was furnished. 

On the 20th of March she returned to town, more than 
ever convinced that she was afflicted with dropsy. The ab- 
domen was now of immense size, and she complained loudly 
of the weight and inconvenience produced by the water, which 
could be felt fluctuating and gurgling whenever she moved or 
changed her position in bed. In addition to the other incon- 
veniences, strangury to a great degree was present ; to which 
may be added severe pains in the loins. No trace of the foetal 
heart could be now discovered, and she mentioned that she had 
not at any time felt the motion of the infant. The souffle was 
audible in the same situation as before. The os uteri was 
found of a conical shape projecting into the vagina, and dilated 
to the size of a six pence, through which the membranes could 
be distinguished. I informed her that labour was about to set 
in, and she preferring to be confined in her own lodging, I gave 
her in charge to an advanced and intelligent pupil. 

March 21st. True labour commenced at 10 o'clock a. m. 
and I saw her at 4 o'clock p. m. The os uteri was then com- 
pletely dilated, and the membranes protruded in a large ball 
into the vagina ; no presentation could be discovered. I rup- 
tured the membranes, when an enormous rush of water took 
place, deluging the bed, and running out upon the floor, so as 
to flood all the part in its neighbourhood. The quantity which 
continued to pour out for a length of time must have been con- 
siderably more than a gallon. Presently a solid substance 
came in contact with the finger, of the nature of which I was at 
first uncertain, but as the uterus continued to act, and it was 
forced lower down, I soon distinguished the soil eminence on 
the upper part of an acephalous foetus; the tops of both ears 
were now felt projecting above the temporal bones, and thoj 



308 Dr. BeaU/s Second Report of the 

edge of the imperfect frontal bone could be felt over the orbits. 
Uterine action came on briskly, and in half an hour she was 
delivered of the infant, which shewed no sign of life, but was 
not in any degree putrid. It was very small, measuring only 
sixteen inches in length, and weighing five pounds. The oc- 
cipital bone was deficient above the foramen magnum, and 
the iervical vertebrae were imperfect along the back, leaving 
the medulla spinalis exposed as far as the dorsal vertebras. 
Anteriorly the foetus appeared to have no neck, the skin of 
the cheeks and chin being continuous with that on the thorax. 
The great quantity of liquor amnii that was present in the 
uterus of this woman, was in accordance with what has been 
observed in other cases where similar monsters were produced. 
Why this should be is diflScult to account for. We know that 
small infants are often surrounded by a large quantity of liquor, 
and vice versa;* and in thb instance, the foetus being small, 
the proportion of fluid might have been in obedience to the 
usual law. But why, when the monster is even above the usual 
size, (as I have seen,) this disproportion should eiist, still re- 
mains to be explained. 

PROLAPSUS UTERI. 

Anne Foster, aged 47 years, admitted September 16th, 1835. 
The tumour projecting from the vulva is of a conical shape, 
the base above. The length of the projection four inches and 
a half on tlie anterior surface ; the breadth of the base, where it 
issues from the vagina, is three and a half inches, breadth of 
apex two and a half. TTie apex was formed by the os uteri, 
which was rounded, swollen, and covered with a glairy, whitish 



* Son abondance est generalement en raiioii infene de la fig^enr, du toliimet 
de la force du foettfft, et de la conttitatioii robnste de la femme : en sorte qn'iui 
foetus de cinque livres, par exemple, nagera dans deux, trois, ou quatre lines 
d'eau, tandii qu'on n'en trouve qu'une livre autour d'un enfant de huit k neuf 
livres. — Vxlfkau, Traits d$ VArt dtt Accouchmetu, p. 161. finisseri Edition. 



^ew Lying-in Hoipital. 309 

matter, through which the suriace conld be seen excoriated. 
The iaverted vagina ma tense, smooth, and very red, and the 
nhole tumour was very painfot on being touched. A portion of 
the urinary bladder had been carried down with the utenls, 
which was made manirest by passing a catheter into the urethra, 
when the instrument passed downwards. She states that the 



310 Dr. Beatty's Second Report of the 

tions in the pelvis, ivben replaced, with more facility than when 
a longer time has been suffered to elapse between the displace- 
ment and the restoration. And the second enabled the vagina 
to become fixed in its situation, when brought in contact with 
the parts from which it bad been forcibly detached. 

HYDROCELE OF THE NECK. 

' In the first Report of the hospital, published in the Dublin 
Medical Journal, September, 1835, the following notice oc- 
curs : — *' An example of that rare disease, hydrocele of the neck, 
presented itself in one of the infants. It was not observed until 
about a week after it was bom, and was then about the size of a 
nut, ^situated immediately below the middle of the left clavicle. 
It has continued to grow rapidly, and is now, at the end of six 
months, as large as a small orange. The coats are thin, and dia- 
phanous, the sac not tense, and no pain appears to be felt in it 
I was unwilling to interfere with it during the infancy of the 
child ; but I propose passing a seton through it at some future 
period." 

The foregoing note of the case was taken in June, and on 
the lldi of September, 1835, the child was again brought to 
the hospital. He is now ten months old. The tumour has in- 
creased In size, and is more tense. 

A small trochar was passed into the under part of the tu- 
mour, and a clear, sherry-coloured fluid was allowed to flow out 
Not intending to pass the seton this day, I withdrew the canula 
after about half the contents had been evacuated, in the hopo 
that the tumour would have been diminished on the following 

day. 

12di. The child was attacked with severe diarrhoea in the 
night The tumour Is as large as before the operation. Me^ 
dicine was prescribed for the intestinal aflfection. 

14tli. The child is now well. The trochar was again intro- 
duced, and fluid of a lighter colour than before escaped. When 



New Lying-in HoKpital. 31 1 

the BBC nas half empty, I withdrew tbe canula, and pasaed a 
probe,- armed with a cotton seton, into the aperture. The point 
of (he probe being pushed to the upper part of the tumour, and 
made prominent, 1 cut down upon it and drew the probd 
through, leaving the seton behind. 

15tU. Pasaed a restless night Tumour lai^r than beRire 



312 



Dr. Beaitj's Second Report of the 



patients treated in the hospital since its foundation in April 

1834. 

Total number of women delivered, commencing April, 1834, 

and ttnuaating August, 1837, one thousand one hundred and 

eighty-two.* 



PRSSBNTATI0N8. 

Head, . .1104 

Face, . . 4orlin295i 

Breech, . . 25 or 1 in 47 ^^ 

Inf. Extiemity , 15 or 1 in 79 

Sup', extremity, 5 or 1 in 236^ 

Placenta, . 4 or 1 in 295^ 

Funis, . . 6 or 1 in 197 

Head and hand, 1 

Twin cases, 18 or 1 in 65i 

Total, 1182 



DDBA 


TION 


OF LABOUR. 


Under 6 hours, . . . 


. 557 


Above 6 and under 12 


. 381 


12 




. . 24 


• 155 


24 




. . 36 


. 43 


36 




. 48 


. 17 


48 




. 60 


4 


60 




. '. 75 


2 


75 




. . 96 


. 2 


96 




, . 136 


1 



Total, 1182 



PBBSSNTATION IN TWIN OASIS. 

Both, head in .... 10 
Both, feet ..... 1 

Both, breech 1 

First head, second feet . 4 
First head, second breech . 2 

Total, 18 



FATB OP CHILDREN IN TWIN 
CASKS. 

Both alive in ..... 13 

Botiidead 3 

One alive, one dead . . 2 

Total, 18 



Total number of children bom, 1200. 

Males, 614, of whom alive, 558, dead, 56 
Females, 586, . . 553, . 33 



Total, 1200 



Total, nil Total, 89 



* This table includes those of the fonner Report. 



New X/ifing'in Hospital. 
Of the 89 children still bom, there were — 



Footling cases, .... 10 

Breech, 12 

Funis, 4 

Twins, 8 

Aim and turning, ... 6 



Forceps cases, .... 3 

Ferforator, 5 

Premature, 12 

Putrid, 8 

Natural, 19 



BIBLIOGRAPHIC NOTlCEiS, 



Reply to Mr. Phillips's Remarks on Mr. Aldridge's Criticism 
on the London Pharmacopoeia. By Dr. Alpridge, Lec- 
turer on Natural History to the Digges-street Medico- 
Chirurgical SchooL 

In the number of the Dublin Journal, published last March, 
appeared a review of the New London Pharmacopoeia, signed by 
me ; and in winch I stated honestly my conviction that the work 
in questipn was not calculated to supply the wants of the medical 
proiession. The grounds upon whicn I based my disapprobation 
of this publication were, 1st., that the list of drugs was mcooi- 
plete, no description having been given of the varieties proper 
to be kept in apothecaries shops, sufficient to enable them to 
be easily recognized, their purity to be tested, and their adul- 
terations if possible removed : '^ thus aloes, sarsaparilla, opium, 
&c., are mentioned, without any clue being afforded to the 
kind which ought to be preferred; although it is notorious 
that the varieties met with in commerce differ in the most 
remarkable degree," And that instead of this useful and indis- 
pensable object having been fulfilled, we find the Pharmacopoeia 
made " an arena for the display of learning in deciding diflS- 
cult questions in natural history and medical riterature.** 2ndly, 
I asserted that '^ with respect to pharmaceutical preparations, 
this book was miserably deficient ; and I proved this assertion 
by the quotation of numerous gross and undeniable examples 
of negligence and ignorance in the directions for preparing 
syrups, ointments, pill masses, &c. Now, inasmucn as " a 
Pharmacopoeia should consist of an enumeration of the simples 
which ought to be kept in the laboratories of compounding 
chemists, together with a formulary for the preparation of all 
those compounds which are not usually found in commerce. 



Dr. Aldridge's Tfepiy lo M-. Philips Damrki, Sfc. 313 



dl6 Bibliographic JVotices. 

Mid useful purpose of requiring fhe emplovment of pure and 
constant medicines ;*' and chemicals would have been prepared 
pore by the manufacturer^ if the Pharmacopoeia had never ex- 
istedy and will continue to be made so with very little ren)ect 
for its formulse. There is no absolute necessity for the medical 
practitioner to be acquainted practically with the preparation 
of calomel, more than there is for his having actually inspected 
the extraction of hepatic aloes. All that is indispensable for 
him in either case, is to be provided vrith the means of ascer- 
tainingy the efficiency of the agents which he employs in the 
cure of disease ; and, when he refers for information to that 
work, which he should consider as the standard, and finds it 
deficient in what he wants, but overloaded with that which is 
unnecessary, he has an equal right to reprehend the over-legis- 
lation which has done too much, as the negligence that has 
done too little. 

But Mr. Phillips has committed himself still farther, sop- 
posing this to be his argument ; for taking it, during a moment, 
for granted, that I am unacquainted with those practical minu- 
tisD which might enable me to perform the processes recom- 
mended by the Pharmacopoeia, are not most medical practitioners 
similarly circumstanced? And, does it not follow, that the 
persons best calculated to make chemicals, are the manufiaicturers 
who have devoted their lives to such preparations? and to 
whom a variety of circumstances may render convenient, pro- 
cesses the most different. Thus Mr. Phillips has, unfortunately 
for himself, proved too much ; for he has proved the very pro- 
position laid down in my review, " That well-informed che- 
mists, having recourse to the best authorities, are independent 
of the Pharmacopoeia, while, for ignorant persons, its directions 
are quite insufficient." 

Having thus shewn that the justice or injustice of my review 
is perfectly unconnected with the strictures advanced by Mr. 
Phillips, 1 shall now examine the correctness of his remarks. 

Some of these remarks are so frivolous and unimportant, that 
the only reason I can assign for Mr. Phillips occupying so much 
paper with them was, the absence of more serious objects of 
reprehension ; thus the translating " nitrici fluidunciam" by 
half an ounce of nitric acid, fills a long paragraph of censure. 
Such an error can scarcely be considered of much importance 
in a review ; and, previously to Mr. Phillips noticing it, he should 
have recollected, that he himself found it necessary to publidi 
a distinct erratum^ some time after the appearance of the Phar- 
macopoaia, containing the correction of errors the most flagrant 
and dangerous. Again, we find Mr. Phillips making himself 
merry at the supi>osed blunder of stating, " pure silver to con- 



Dr. Aldridge'B Reply to Mr. PhilUpt'i Remark$,8fc. 317 

tain gold and copper." But his facetious liumour woidd not 
have presented a very palpable object, had be quoted th» pas- 
sage correctly ; " the puresilveroftbe jewellers" waa the phrase- 
ology which I used. 

Many of these remarks exhibit want of candour, and misre- 



318 Bibliograpinc Notices. 

friYolous, and that many are uncandid efforts to palliate what is 
confessedly erroneous, I shall examine, in detail, the remaining 
preparaticms which he has volunteered to defend. The first 
preparation which I shall bring before the notice of the reader, 
i» the Ferri Potassio-Tartras of the new Pharmacopceia, a direct 
.combination of bitartrate of potash with peroxide of iron, whidi 
Mr. Phillips asserts to be identical in composition with the 
"Ferrum Tartarizatum," of the old Pharmacopoeia. His asser- 
tions with respect to this preparation are so singular, that I shall 
quote his own words : 

*< The critic says, that in preparing what he calls the old tartar of 
iron by exposing iron to the action of bitartrate of potash, wat^r,and air, 
the iron, influenced by induction from the potassium, only acquires 
a proto-state of oxydation. From this statement it is evident that the 
cntic is ignorant of the fact, tbtt when iron is acted anon by bitar- 
trate of potash and water, the oxygen, which the metal first acquires, 
is derived from the decomposition of water, the hydrogen of which is 
OTolved in the state of gas." 

I feel repugnance, I confess, in being obliged to comment upon 
this passage, for I am forced by it to infer, either that Afr. 
Phillips is unacquainted with the meaning of the word " induc- 
tion," or that he intentionally endeavours to mislead his readers. 
By this term is simply understood the influence which a body, 
charged with any kind of electricity, exerts over another, either 
charging it with the same kind, ii it be previously neutral, or 
diminishing its excitement, if it be before charged with the same 
kind in a minor degree. It is a necessary result of the charac- 
teristic attractions and repulsions, which the electrical fluids 
exercise towards each other. Yet, Mr. Phillips pretends to dis- 
cover in my assertion, " that the positive potassium exerts an 
induction over the less positive iron," an aflSrmation of the 
source from whence the latter obtains its oxygen — a most losical 
conclu»on truly. But, that this induction, which Mr« Phillips 
does not appear to understand, is actually exerted, can be proved 
by the following considerations. Iron will not rust when par- 
tially immersed in a solution of carbonate of potash : what is the 
cause of this effect, if it be not produced by the presence of t^e 
positive potassium, destroying the electrical energy of the iron ? 
Again, one part of iron, partially immersed in six parts of cream 
of tartar, moistened with water, (these being nearly the atomic 
proportions,^ suffers a very slow and imperfect oxydation, and 
that which is acted on will be found mixed with the bitartrate 
of potash in the form of a white sparingly soluble proto*tartar. 
Lastly, if you place some coils of iron turnings in a mixture of 
water and freshly prepared proto- tartar of iron, in the course of 



Dr. AWridge's Reply to Mr. Phillips's Remarks, 8fc. 319 

a few hours a proportional qnantity of the latter will dtssolfe, 
foraiinga very aart['CoJouredsolution,nhi(^ will preeentall the 
characters of perbrtar of iron. In the latter case, tlie excess of 
iron overcomes the inductive energy of the potaasiuni, and some 
slips of copper witt be found to act in a similar manner. Here 
we have presented.to uaa very beautiful play of mutuid indue- 



320 Bibliographic Notices. 

very curious properties. It is very sparingly soltible in water, 
and yet throws down peroxide of iron^ when boiled with carbon- 
ate of potash. We are here presented with a union of the pro- 
pertiesy separately possessed by the described tartars of iron, 
and what more distinctly points out its composition is, that when 
pure proto-tartar, in excess, is boiled with a solution of tartar of 
the sesquioxide, this green sediment is thrown down, and the 
supernatant liquid is left completely colourless. It is to be 
remarked, that this green sediment, which we have just seen to 
be a combination of proto-tartar and pertartar, is found in much 
greater proportion in the tartar of iron of the Dublin Pharma- 
copoeia, where a much smaller quantity of iron is employed; a fact 
to DC expected from the experiment already mentioned, in which 
the presence of an excess qf iron hastened remarkably the 
oxydation of the proto-tartar.* 

The reader will excuse these details, not only because they 
expose the unwarranted assumption of Mr. Phillips's assertions, 
but, likewise, that they disclose much that is interesting with 
respect to a preparation which has been hitherto but imperfectly 
unaerstood. Jn conclusion, I may remark, that Mr. Phillips has 
exhibited great negligence, or an intention to deceive, in quot- 
ing Dr. Barker as an authority in favour of his opinion. In page 
2M of his Translation, Dr. Barker distinctly states, ** In this 
process, a triple salt, the tartrate of potash and iron, is formed ; 
the atom of tartaric acid, which gives acidity to the tartar, being 
neutralized by protoxide of iron." 

The next remark of Mr. Phillips, which I shall bring before 
the attention of the reader, is one which he has hazarded with 
respect to my criticism on the process for Antimonii Potassio- 
Tartras. Having mentioned that tartar emetic is made by boil- 
ing cream of tartar with crocus of antimony, I quoted a passage 
from Berzelius condemnatory of this method of preparation. 
Mr. Phillips meets this by saying, that the quotation from Ber- 
zelius, 

<< Has nothing to do with the process ; for I assert/^ he continues, 
« in direct contradiction to the critic, that crocus of antimony is not 
used by the College. Crocus of antimony is prepared by mixing, 
deflagrating* and fluxing a mixture of equal weights of sesquisulphuret 
of antimony and nitrate of potash ; and, the crocus is separated me- 
'chanically from the saline matter. In the College process, the same 
ingredients are employed ; mixed, however, with some hydrochloric 



* It is also to be observed, how completely the fact mentioned in the preceding 
note accounts for the non- precipitation of proto>carbonate of iron, when the sedi* 
oMnt was boiled with carbonate of potash* 



Dr. Aldridge's Reply to Mr. Phillips's Remarks, 8fC. 321 

tcid, this mixture is merely deflagrated, and the saline admixture is 
separated by washing." 

Now, tins certainly is a very strange method of arguing ; so, 
forsooth, the identity of a compound depends upon the mode of 
obtaining, and not upon its composition ; either sublimed or 
precipitated proto-chloride of mercury cannot, therefore, be 
calomel. Carbonic acid, obtained by the action of an acid on 
chalk, cannot be the sanf^e as that got by burning the diamond. 
I wonder Mr. Phillips did not think of this method of reasoning, 
when he so vehemently insisted on the identity of the new and 
old tartars of iron. But Berzelius' ideas of chemical identity 
are very much at variance with Mr. Phillips's. He mentions 
several methods of obtaining the crocus ; amonj^st the rest, par* 
tially dissolving the sulphuret in muriatic acid, then throwing 
into water, when the oxide, formed by the decomposition of the 
chloride, uniting with the remaining sulphuret, forms " crocus.'* 
Surely Mr. Phiflips must have forgotten Proust's ** washed cro- 
cus of antimony," when he mentioned washing as a distinctive 
character of the College preparation To examine how far the 
presence of hydrochloric acid interfered with this product, I 
took 120 grains of the material, deflagrated according to the 
College directions, and having boiled it in distilled water, foupd 
that 63-5 grains were dissolved ; consisting of GO-5 grains of 
mixed chloride and isulphuret of potassium, and sulphate of 
potash, with three grains of kermes and golden sulpiiuret. The 
insoluble residue was of a safiron- brown colour, and amounted 
to 56-5 grains, from whence twenty-three grains of sesquioxide 
was extracted, by boiling with an excess of bitartrate of potash, 
the remainder was soluble, with the exception of a small quan- 
tity of blackish powder in hydrochloric acid, evolving, durine 
its solution, sulphurated hydrogen gas. It evidently possessed 
the composition of crocus of antimony, with some excess of 
sesquioxyde ; and, if Mr. Phillips entertained any doubt as to 
the accuracy of ipy experiment, he is at liberty to refer to page 
190 of his own Translation^ where he will find the following 
paragraph : 

*^ By the present formula, an oxvsulphuret is obtained similar, in 
composition, to the Crocus Antimonii of the Pharmacopoeia of 1788.** 

It is plain that Mr. Phillips's only reason for having recourse to 
so ridiculous a quibble is to shield himself from an objection, 
that he knew he had no means of honestly refuting. 

In answer to mv objections urged against Baup's process, for 
obtaining iodide of potassium, Mr. Phillips says: 

VOL. XII* MO. 35. 2 T 



322 Bibliographic Notices. 

** I assert that there is no danger of excess of potash, when due 
care is taken ; and, as to the precipitate of peroxide of iron, of which 
the critic talks about, there is none ; and, so deplorably ignorant is 
he of tlie facts of the case, as to suppose, that when proto-iodidc of 
iron is decomposed by carbonate of potash, the precipitate obtained 
is a sesquioxide, instead of proto-carbonate." 

It is astonishing with what facility Mr. Phillips changes his 
opinions, according as the convenience of the moment demands ; 
the precipitate, in this instance, requires as much washing and 
exposure, as that which he calls " sesquioxide of iron ;" and 
which, in another place, lie asserts not to contain one per cent. 
of proto-carbonate ; yet, in the present case, without any assigned 
reason, he will not allow the production of any sesquioxide. 
But let us compare Mr. Phillips's assertions with those of Ber- 
zelius, who says, " II est difficile, d'executer cette operation, de 
inani^re a feviter la presence, d'un exces de potasse." And 
again, •* cette perte provient, soit de la filtration, et du lavaget 
floit de ce que le fer passe a un plus haut degr^ d'oxidation se 
pr^cipite dans cet 6tat, et entraine avec lui une certaine quan-t 
lit6 d'iode."* 

I asserted in my review that pure nitrate of silver, which has 
never received organic contact, will not become blackened in 
the sunshine : and I now repeat that assertion, in which I am 
borne out by the experience of every person who has ever been 
engaged in its manufacture. " If so, considerable pains have 
been taken," says Mr. Phillips, " by the authors of the Dublin 
Pharmacopoeia to prevent the occurrence of what never hap- 
pens." But here again I must join issue with Mr. Phillips; for 
although pure nitrate of silver remains unaflfected in the light, 
that which has been rolled in paper, and collected particles of 
dust, will very soon become dark upon exposure. 

The next of Mr. Phillips's remarks which I shall refer to are 
those on the protoxide of mercury. When after taking all pos- 
sible advantage of a typographical error, whereby I was made 
to ascribe a much greater impurity of proto- chloride of mercury 
than I had intended, he proceeds to say, that he had prepared 
protoxide of mercury by decomposing calomel with lime water, 
f* And in the mode," he continues, "I presume the critic would 
have adopted, had he performed it — that of attempting a/ailure.** 
He then details an experiment, wherein, after having saturated 
the excess of lime in the supernatant liquid by nitric acid, he 
detected as much chlorine as the calomel could have theoreti- 
cally yielded. Now, as Mr. Phillips was, according to his own 
account, ** attempting a failure," it was easy for him to employ 



* Traite de Chiroie, traduit par M. Esslinger. T. iii. p. 375. 



Dr. Aldridge's Reply to Mr. Phillips's Hemarks, Src. 323 
commercial nitric acid, by means o? which he could insure a 



324 Bibliographic Notices. 

publishers considered themselves entitled to prohibit any 
other translation but what might be executed. by him. But 
whilst we acquit Mr. Phillips of any Quixotic interference 
in the concerns of others, what opinion are we to form of that 
corporation, which has surrendered the conduct of such a work 
to a gentleman, who, whatever may be his scientific attainments, 
is not even a member of the medical profession. 

Before I conclude, I must express my regret at the tone 
which Mr. Phillips has given to this controversy. It can 
scarcely be considered consistent with gentlemanly feeling or 
philosophical dignity to indulge in invective or vituperation. 
Armed strong in nght, I have found no necessity for such 
weapons ; and it is generally considered to betoken great de- 
bility in argument, where means so vile must nece;ssarily be had 
recourse to. Chemistry, perhaps, of all the sciences, is that 
which most frequently engenders angry feeling. Mathematics, 
the science of calculation, elevates its votaries above all per- 
sonal contention. Natural history, the science of observation, 
encourages a harmony amongst fellow-men, similar to what is 
perceived in the great creation. But chemistry, depending on 
experiment for its study, identifies itself so much with our self* 
esteem and ambition, that envy, hatred, and all uncharitableness 
spring too frequently from its pursuit. The reader will remem- 
ber it was in the Alchemist Ben Johnson portrayed the Angry 
Boy — a character which Mr. Phillips appears anxious to re- 
hearse. I can assure him, however, of the most perfect good- 
humour on my part, as long as his scurrility is directed merely 
towards myself. 

But I cannot, with equal complacency, regard the super- 
cilious manner with which he has treated my friend, Mr. 
Ferguson. I have thought it unnecessary to defend the processes 
which I have mentioned on this gentleman's authority, partly 
because in doing so I should forego his valuable assistance, as 
he is at present absent from this country, and if requisite he is 
well able to take his own part, and partly because they were 
not connected with the strictures which I thought proper to pass 
on the College preparations. But, in answer to Mr. PhiUips's 
unwarranted attack, I may be permitted to say, that Mr. Fer- 
guson is a gentleman, who has already provea his talents by 
some admirable chemical papers in this Journal — one of which, 
on the " Ceratum Saponis," is probably the occult cause of his 
present vituperation. He is not, however, a man of one idea — 
a pure chemist ; but possesses extensive mathematical and lite- 
rary information — a man whose kindly disposition will always 
excite esteem, while his hish moral principle will command 
respect. Such a man may dways despise the hireling pen of a 
literary "Pistol." 



Mr. Todd's Cyelopadia of Anatomy tuut Phyiiology. 823 

The Cyclopeedia o^ Anatorm and Phytiology. Edited by 
Robert Todd, M.D., Professor of Physiology, and General 
and Morbid Anatomy, in King's College, London, &c. 

We have read nilh pleasure the twelfth part of ibis valuable and 
interesting work, which fiilly sapports the character obtained for 



SCIENTIFIC INTELLIGENCE. 



Extracts from the Proceedings of the Medical Section of the 
British Association. — A demonstration or lecture, by Dr. Mackin^ 
'tosh, on the Pathology and Treatment of Dysmenorrheea, was 
listened to by a large audience, with excessive interest. As the 
non- professional journals could not, of course, give any detailed 
account of this demonstrationt we shall be somewhat more parti- 
cular than usual on this subj^. Dr. M. laid on the table at least 
a score of uteri, all presenting morbid contraction or stricture of 
the OS uteri, in a greater or less degree. Some of them were all 
but closed — some would scarcely admit a pig's bristle, and all were 
abnormally contracted. With the history of most of the cases he 
-had been acquainted, and they all laboured under painful, and, 
generally speaking, scanty menstruation. This contraction of a 
natural aperture, he regarded as the result of some inflammatory 
action in the parts themselves, or in their vicinity, more frequently 
than of any other cause. The straining of the uterus to get rid of 
the secreted menses, might explain all or most of the phenomena 
of dysmenorrhsea. The treatment, independently of constitutional 
means, consisted chiefly in removing inflammation, by the appli- 
cation of leeches (through the medium of a tube) to the os uteri 
itself — and where chronic contraction obtained, to introduce metal- 
lic bougies till proper dilatation was procured. He related several 
most important and interesting cases in illustration. The patients 
were chiefly dispensary patients; but afterwards he began to have 
private practice in the complaint, especially among the wives, 
daughters, and relations of medical men. It was objected that such 
operations would not be submitted to by English females. But 
Dr« M* triumphantly replied that he never urged, seldom indeed 
proposed the operation. He explained to the parties the nature of 
the disorder, and the remedy wnich he had sometimes found sm> 
cessful ; bat recommended the patients to try all other means, and, 
if they pleased, other practitioners, for the cure of their maladies. 
After a time, the patients themselves, or their friends, would propose 
the operation, which he always refused to do. till ardently solicited 
to do so. In this way he steered clear of all scandal. 

The second Report of the Sub-Committee, appointed by the 
Association, to investigate the Motions and Sounds of the Heart, 
was read by Dr. Charles Williams. 



n 



Scienti^ Intelligence. 327 

. Before describing tbeir lost iuvestfgatioas, the Committee Btftled 
that they had Ibuad frequeat opportuoiliea of confirming the con- 
clUBiouK or ibeir former reseorcbes on the natural soands of the 



328 Scientijic Intelligence. 

pathology and dittgnosis of diseases of the heart and arteries, the 
knowledge of which would be of direct practical adfantage. These 
points the Committee propose to investigate, if the Association 
think fit to re-appoint them to this office. 

Mr. Brett then read a paper "On the Physical and Chemical 
Characters of Expectoration in different Diseases of the Lung^ 
with some Preliminary Remarks on the Albuminous Principles 
existing in the Blood." 

The remarks on the blood referred more particularly to a general 
view of the albuminous principles existing in that fluid. The sim* 
plest view which could be taken of the vital fluid, is that which 
refers its constitution to a mixture of fluid, or soluble and insoluble 
albumen — the one constituting what is termed the serum, the other 
the crassamentum, or cruor. The author of the paper then pro- 
ceeded to relate the different opinions which had been published 
on the specific gravity of the blood, quoting the statements of Ber- 
zelius, Gmelin, Dumas, and other chemical philosophers of dis- 
tinction ; at the same time remarking, that all these statements did 
not difiPer materially from each other, and might be considered as 
depending upon the fact, that the specific gravity of the blood 
might differ slightly, not only in different individuals, but in the 
same individual at different times. He then noticed the different 
modifications of albumen existing in the serum, which he divided 
into three forms : — 1st, Soluble or free albumen, capable of under- 
going coagulation by heat; 2ndly, Albumen in combination with a 
basic body, viz., soda; and, Srdly, A form of albuminous matter, 
which he termed the colourless self-coagulating albuminous prin* 
ciple. 

The crassamentum, as it is commonly called, of the blood, he 
also considered as made up of more than one form of solid albu^ 
minous matter ; viz., of solid albumen capable of undergoing deco- 
loration by ablution with water, and of solid albumen incapable of 
being decolorated by the same process ; the former being insoluble, 
and constituting what is commonly understood under the name of 
fibrine, the latter soluble in water, and frequently designated red 
particles or hamatosine. Some remarks then followed on the mi- 
croscopic examination of the blood, and on the different forms of 
the globules in different animals. The author then proceeded to 
detail the various physical characters of the expectoration in the 
healthy condition of the lungs, as well as in its varied morbid 
states. The physical characters of saliva were entered upon, and 
the globularity of its opaque portions alluded to. The physical 
characters of expectoration in the pituitous catarrh ofLaennec 
were then detailed; also those of the expectoration in acute and 
chronic bronchitis --in haemoptysis, or pulmonary apoplexy —in 
pneumonia — and, lastly, in different stages of phthisis. The che- 
mical characters of these different modifications of ex[>ectoration 
were then fully treated of, and reference made to a tabular arrange- 
ment which the author had embodied in his papers, exhibiting the 
action of certain re-agents^-first, on saliva, and then on the differ- 



Scientific Intelligence. 329 

eat forms of sputa, the physical characters of which had heen 
already fully noticed. It was remarked that saliva did not contain 
any soluble albumen capable of undergoing coagulation by heat ; 
neither did it contain any solid albuminous matter, the main bulk 
of the solid contents of that secretion being mucous. The mode of 
analysis adopted was, to deject saliva in cold water, and then sub* 
ject ihh filtered fluid to the action of certain re-agents ; another por. 
tion of saliva was then dissolved in a caustic alkali, and the alka* 
line solution subjected to the agency of certain tests. The qnan« 
tity of solid matter in a given weight of saliva was also announced, 
as well as the saline matters, and their chemical nature stated : dif« 
ferent authorities bearing on the subject were quoted, especially 
the statements of Berzelius and L. Gmelin. The chemical charac* 
ters of expectoration in pituitous catarrh were then described, and 
a mode of analysis was stated to have been adopted analogous to 
that employed in the case of saliva : this modification of sputum 
was regarded as purely mucus, possessing no albuminous matter ; 
it was found to contain a very small proportion of solid matter in a 
given weight, but the quantity of saline matter was found to be con. 
siderable, when compared with the quantity of solid matter ; and 
this saline matter the author's experiments lead him to conclude 
was diminished in quantity as the disease progressed. The che* 
mical nature of sputum of the acute and chronic bronchitic charac- 
ter was then entered upon, and noticed as differing in certain re* 
spects from the preceding form of expectorated matter, in contain- 
ing, for example, a much larger proportion of solid matter in a 
g^ven weight than was found in simple pituitous expectoration, and 
generally a smaller proportion of saline matter ; it also dififered in 
containing, generally speaking, small quantities of soluble albumen 
capable of undergoing coagulation by heat. 

Pneumonic expectoration was then treated of, and noticed as 
principally made up of a tough, mucoid secretion, intermixed with 
blood, to which last was owing its peculiar rust or brick- red colour, 
and also its powers of undergoing, to a certain extent, coagulation 
by heat when mixed with water and filtered ; it was also found to 
dififer from most other forms of expectorated matter, in containing 
no inconsiderable quantity of oxide of iron, derivable from the 
blood with which it is impregnated. Phthisical expectoration was 
the last fonn of sputum, the chemical characters of which were 
described. It was noticed as dififering materially in different 
stages of the disease; in the earlier and middle stages scarcely not 
at all; for (he most part, at least, differing from the expectoration 
met with in chronic or acute bronchitic affections : in the latter 
stages, however, not un frequently possessing the characters of a sim- 
ple collection of puriform matter, containing very large quantities 
both of soluble and solid or insoluble albumen, much solid matter 
also in a given weight, with the ordinary saline matters found in 
other varieties of sputa, superadded to which was a notable propor. 
tion of oxide of iron. It was stated that in no disease, except 
phthisis, did the expectoration contain so much soluble albumen 

VOL. XII. NO. 35. 2 u 



330 Scieniific Intelligence: 

capable of ttndeigoing cdogulatiob bj bent ; and also in no dkkaUsstr 
except pneumonia, was theve so large a proportion of solid matter 
in a fi^iven weigbt of the expectoration : tbis observation re^nitif^, 
bowever, to tbe sputum in tbe latter stages of pbtbi^s, where it 
puts on tbe character of a collection of purifornr matter. Allusioii - 
was then marie to tbe fatty matter existing in expectorated fluids, 
which was found to be tbe same in quality in almost every irauiety 
of sputum, but differing in quantity, being much grealer in qnaa- 
tily in well-marked phthisical expectoration than in any other 
variety. The fatter matter was peculiar, too, from the high tem- 
perature which it required for its liisioni it being oonsiderafoly 
nigber than that necessary for tbe fusion of tbe more ordinary 
forms of futty matter, and even biglier than that required for ebo- 
lesterine; this fatty matter was soluble in alcolu^ and ether, being* 
deposited from tbe former when its boiling solution cooled. Tbe 
author also referred to the power which a galvanic current, even oC ' 
low intensity, possessed of coagulating the aqueous fluid, obtained 
either by digesting saliva, or any of the modifications of expecto- 
rated matter before alluded to, in water, and filtering the fluid. 
This coagulation was not regarded by the author as proving the ^ 
presence of albumen, because, in cases in which the galvanic cnr- 
rent effected tbe change in question, tbe most delicate re*agent8 
wttli which chemists are acquainted for the detection of aibomen, 
failed to detect the slightest trace. The author then detailed hia 
experiments on crude und softened tuberculous matter ; he sub- 
mitted the former to the action of the same re-agents as he employed 
to re-act upon ordinary fibrine, and was led to conclude that the 
crude tubercle did not differ chemically from solid albumen or 
fibrinous matters. The mode of analysis employed in examinittg* 
the crude and softened tubercle, was the following: it maybe ob*- 
served, that the erude tubercle was examined side by side, with 
ordinary fibrine ; the crude tubercle was dissolved in a weak solu- 
tion of caustic potass ; a similar solution of fibrinous matter was 
obtained, and both submitted to the action of tbe same re^agents, 
with results as nearly similar as possible. The aeents employed 
were the mineral acids, acetic acid, and ferrocyanide of potassium, 
ttncl. galls, corrosive sublimate, &c. Tbe soAened tubercnlous 
matter was first dejected in water, and then filtered ; the fillerod 
floid, when submitted to re-agents, was found to contain soluble 
albumen ; that portion of the tubercle insoluble in water, was de«* 
jected in a weak alkaline fluid, by which a solution was obtained. 
This alkaline solution, when submitted to tbe necessary re-agents, 
indicated tbe existence of solid albuminous matter or fibrine ; bence, 
tbe softened tubercle was regarded as analogous in its chemical 
characters to purulent matter. Experiments were then made on 
tbe tuberculous matter which had undergone perfect softening, and 
the result was, that the latter was chemically identical with pus;' 
from which it was deduced, that fibrinous matter was, by a prooesS' 
of soltening or fluifaclion, converted into actual pus; and hence, a 
fruitful source of tlie abundantly albuminous fluid foand in tlieex-' 



Scientific JtOdUgeme. 331 

cectoration of patienU, in tbe laller tUge of pfatliiiical diaeoaa 
The author then concluded hia paper, by slating tbe results of a 
quantitative analysis of the expectoration of a markeJ puribnn 
cbaracter, obtained from a patient in the last sta^e of phthisis. It 
was found to consist of.— water; albuminous matter, vitfaalittla 



332 Scientific Intelligence. 

fiection of the nerve on both sides, to enable the animal readily to 
recogpiize bitter substances ; eighth, that it may probably partici- 
pate with other nerves, in the performance of the function of the 
sense of taste, but it certainty is not the special nerve of that sense ; 
ninth, that the sense of thirst does not depend entirely upon this 
nerve. 

Pneumogcuiric, or Par Vagum Nerve, — ^From the result of thirty 
experiments on this nerve, he is satisfied that severe indications of 
suffering are generally induced by pinching, cutting, or even stretch* 
ing this nerve. Powerful respiratory movements were excited in 
some of the animals, when the trunk of the nerve was compressed 
for a few moments by the forceps. 

J^haryngeal Branches of the Par Vagum, — From seventeen ex- 
periments performed on dogs, either when alive, or immediately 
after being deprived of sensation, he concludes, that these are the 
sole motor nerves of the constrictors of the pharynx, the stylo- 
pharyngeal and palatine muscles ; and that the sensitive filaments 
contained in these branches of the par vagum are exceeding few, 
if under ordinary circumstances they exist at all. 

Pharyngeal Branches of the Par Fagum.^ From his experiments 
on these nerves, repeated and confirmed in various ways, he con- 
eludes, that all the muscles which move the arytenoid cartilages, 
receive their motor filaments from the inferior laryngeal or recurrent 
nerves. That one only of the intrinsic muscles of the larynx receives 
its motor filaments from the superior laryngeal, viz. the crico^thyroid 
muscle, and that consequently, the only change which this nerve can 
produce upon the larynx as a motor nerve is, that of approximating 
the cricoid cartila^^e to the thyroid,->in other words, of shortening 
the larynx ; and that the sensations of the larynx depend upon the 
superior laryngeal nerve. These experiments are completely sub* 
versive of the statement of Majendie, that the inferior largyngeal 
nerves supply those muscles only which open the glottis, while the 
superior supply muscles which shorten the glottis. They also 
illustrate, in a very satisfactory manner, the causes of the dyspnoea, 
amounting in some cases to strangulation, when the inferior laryn- 
geal nerves are cut or compressed. 

He hasalso satisfied himself, that when any irritation is applied 
to the mucous membrane of the larynx in the natural state, this 
does not excite the contractions of these muscles, by acting directly 
upon them through the mucous membrane, but that this contrac- 
tion takes place by a reflex action, in the performance of which the 
superior laryngeal nerve is the sensative, and the inferior laryngeal 
is the motor nerve. He is also convinced that the muscular con- 
tractions of the oesophagus are not called into action by the ingests^ 
acting directly as an excitant upon the muscular fibre, through the 
mucous membrane, but by a reflex action, part of the oesophageal 
filaments acting as sensitive, and others as motor nerves. Our space 
wiU not permit us to state any of the results obtained from the ex* 
periments on the other branches of the par vagum* 

Spinal Accessory.f'^ThiB nerve was cut across in seven dogs at 



Sdeotific InteUigeMe. 333 

its exit from the creninm, and qd effect npon (he voluntary move- 
meots or ibo muulea or {he neclc could bn observed. Id other 
animals the nerve was first cut across oa ooe side, and then a weak 
dose of pruasic acid given. This was frequently followed hy 
powerful, stow, and regular respiratory movements) during some 
of which distinct contractions of the stemo-mastoid muscle were 
observed in unison with the other musoles of inspiration. — Medico- 
Chirurgicai Semete. 



334 SdefU^ JnteUigence. 

amy be said to have falkn A Bacrifiee to his too ardeat pur^t df 
science^ as. the fatal fever, which terminated his sliort but distin- 
^itshed career, was caused by close applicaiton, whilst in a delicate 
fiCate of health, in pfepariag for the British Association au elaborate 
eritieal illustrationi through its pniniti?e dialects, of the Ancient 
Geograpliy and History of Gmil and the British Isles. — Etming 

* Sir A. Cooper in Edinburgh^-^On Tuesday, September 5lh, 
the College of Sniip^eons of Edinburgh entertamed Sir Astky Cooper 
to dinner in the Royal HoteL Besides a numerous attendance of 
the College, there were present Dr. Abercrombie, Professors Hope, 
Alison, Sir C. Bell, &c., and many medical gentlemen formerly in 
the public service. Sir 6. Bollingall was m the chair; and Mr, 
Lothian, Treasurer, Drs. Gardiner and J. Campbell, acted as crou- 
piers. After the usual loyal toasts, the health of Sir Astley Cooper 
was drunk with the warmest enthusiasm, which Sir Astley acknow- 
ledged in a speech of great good humour, and the utmost kindli- 
ness of feeling. He stated, that fifty years ago, in the year 1787, 
considering that his medical education could not be complete with- 
out studying in Edinburgh, he became the pupil of Cullen, Black, 
Grft go ry, &c. He mentioned, that when he came to Edinburgh, 
on Wednesday, the first place to which be drove was his former 
lodgings in Bristo-street : that amidst all the improvements in 
Edinburgh, he found the locality of his former residence very little 
changed ; that he saw the very room and the closet, endeared by 
former recoDectibns ; and that when he looked back upon those 
days, and reflected on the fame and success whic4i had attended 
him through life, he was tempted to fall down on his knees and 
thank that Providence which had so conducted him. Seeing so 
jnany members of the profession in the company, he affectionately 
exhorted them to attain the utmost skill in their profession, never 
lo attempt to rise by depressing another, and never to let go their 
integrity and high moral character. He paid high compliments 
to the great men under whom he bad studied, and was delighted 
to find that the reputation of the University was still upheld by 
those who had succeeded him. He highly approved of the adop- 
tion of Sir C« Bell as professor of surgery. In the course of the 
evening, Sir G. Ballingall announced that be had been informed 
by letter from the Lord Provost, who regretted that his health would 
not allow him to be present at the meeting, as he had been invited 
to be, that the freedom of the city of Edinburgh had that day been 
conferred upon Sir Astley, whose health he again proposed in the 
capacitv of the youngest citizen of Edinburgh. The evening was 
spent throughout in the utmost harmony, and the meeting did not 
sepanUe till a late hour. — Edin. Paper, 



DUBLIN JOURNAL 



336 Dr. Robertson's Case of Rupture of an 

period he suffered from stifihess and pain in the right side of 
the neck, resembling what is usually termed a crick, accompa- 
nied by shooting pains over the whole right side of the head : 
occasional attacks of giddiness, slight strabismus, and double vi- 
sion foUowedythe last to sa great a degree that he was forced to 
give up his favourite amusement of hunting, every gate, fence, 
&c appearing to him double. The sight was particularly con- 
fused when looking straight forward, and still more so to the right 
He likewise lost all idea of distances. On shutting either eye 
vision again became distinct. The motions of the iris in each 
eye were perfectly natural. The appetite was good, and bowels 
regular. Pulse rather full, but in other respects natural. In 
addition to the above symptoms, in December, 1836, he began 
to suffer occasionally from a feeling of numbness and coldness 
of the left arm and leg. At this period he placed himself 
under the care of Professor Alison and myself. Looking upon 
the symptoms as indicating a tendency to an apoplectic attack, 
we placed him upon a regulated diet, his bowels were kept open, 
leeches were ordered every second or third day to the temples 
or behind the ears ; he had cupping glasses applied upon two or 
three occasions. The head was shaved, and sponged several 
times a day with cold water, and he was desired to take regular 
but moderate exerdse, and to reside quietly at his seat in the 
country. Under this treatment his health was much improved, 
and his vision almost perfectly restored. 

About the middle of January last he first discovered a swel* 
ling on the right side of the neck, accompanied by enlarged 
tonsils, slight sore throat, and some difficulty in swallowing. 
The swelling in the neck was supposed to be simply an enlarged 
gland, and did not attract particular notice. Leeclies were 
ordered to be applied from time to time, more especially if it 
shonld inflame or become painful. 

. On the 20th of March, without any premonitory symptoms, 
at ID o'clock, p. M., a sudden gush of blood took place from the 
niK)ath ; it was discharged in gulps or mouthfuls in rajnd snc-i 



Aneutism of the Common Carotid. 337 

cession ; it ceased spontaneously after half an ordinary wa$h- 
hand basinful of blood had been lost; he retired to bed^ and 
slept very soundly during the whole night. 

The following morning he rose at 8 o'clock, but had 
scarcely reached his dressing room when ihe haemorrhage re- 
tumedy andy to use his own expression, the blood literally 
poured from his mouth ; he soon fainted and fell upon the floor, 
breaking a foot pail in the fall ; about fifty ounces of blood 
were at this time discharged by the mouth, and a considerable 
quantity must have passed into the stomach, as the stools after- 
wards consisted almost entirely of coagulated and grumous 
l)lood. By the two haemorrhages he must have lost upwards 
of one hundred ounces of blood. The bleeding now ceased, 
and he rallied a little and procured assistance. He remembers 
<]istinctly that at this time he shook very much, and felt exces- 
sively cold. Having taken a laxative the previous nighty he 
had now an urgent call to stool, and was carried by his servant 
lo the water closet, when he had a copious alvine evacuation, 
after which he again fainted. On recovering he still shook 
very much, and felt very cold ; he was put to bed, and warm 
bottles were applied to the feet Dr. M'Intyre of MuthtU, 
having been sent for, arrived about 10 o'clock, and found Major 

in a very exhausted state, his extremities cold, the 

pulse at the wrist scarcely perceptible, and giving forty-five beats 
in a minute. Dr. M'Intyre, perceiving the urgent nature of the 
case, sent off an express to Edinburgh for me. I reached Major 

■ * s teat about midnight, and found him perfectly com* 
posed and tranquil, with the pulse scarcely perceptible at the 
wrist, and continuing to beat about forty-five strokes in the 
minute. Oti examining the neck I found a tunoour extending 
from near the angle of the jaw to within one inch oC the ster- 
num, and projecting laterally to about three inches. ^Its sur* 
face was smooth, equal, and rounded, and a very obscure pulsa^ 
tion could be detected. Judging from tlie state of the circula- 
tion, and from there not having been the slightest return of 



338 Dr. Robertson's Case of Rtiptureof an 

bleeding since 8^ a. m. that there was not immediat* danger^ l 
thought pr(^)er to postpone attempting to secure the carotid 
below the seat of the aneurismal swellings (evidently the onljr 
surgical resource that was left me)> in order that I might have 
the benefit of day-light for the operation ; and I sent off te 
Stirling for Mr. Forrest, that we might have the advantage of 
his advice and assistance in so important a case. 

In consequence of the aneurism being seated so low down 
in the neck, the external incision was limited to little more than 
an inch, following the course of the stemo-mastoid from the 
Btemum upwards. On dividing transversely the stemo-thyroid 
and a few fibres of the stemo-hyoid muscles, a narrow projec- 
tion of the aneurismal tumour, passing between the artery and 
trachea, was brought into view; so narrow that lat first sup;^ 
posed it to be the artery somewhat dilated, and passed the 
aneurism needle round it It was, however, about double the 
Ate of the artery, and its coats were thinner- than natural. Oa 
examining the parts more minutely, I discovered the carotid dis- 
placed laterally by this prolongation of the saa The pidsa* 
tions were feeble, though perfectly distinct ; the situation at 
which it was exposed was within a finger^s breadth of its origin 
from the innominata, and when the finger was applied to this 
point the oirotid was felt pulsating on its palmar,-^hie innomi- 
nata on its lateral surface. Immediately above this point die 
vessd swelled out into the aneurismal tumoiu*. The ligature 
was therefore applied within half an inch of the origin of the 
artery. During the performance of the operation neither vein 
nor nerves were seen. Tlie operation itself was necessarily 
tedious and difficult, in consequence of the limited exietAxii 
die external incision, the deep situadon and unnatural displace* 
ment of the artery, and the importance of the organs by wbidi 
it is surrounded. At one time I thought it would have beetl 
necessary to have divided the sternal attachment of^the stettio- 
mastoid, but this was avoided by relaxing the muscle and ditiw- 
ing it outwards. The vessel was no further separated from its 



Aneuritm of the Cummon Carotid. 339 

attachments tliBi) wasneceaaary for tlie simple paaaage ofllie 
aneuriam needle. On tightening the ligature all pulsation ceased 
in the tumour, and it was reduced nearly a third in hulk. No 



340 Dr. Robertson's Que of RujUuref 8fc. 

indicating disease of the brain> and probably ^xote from an al- 
tered state of the circulation through that organ> aa they have 
completely disappeared since the aneurism was cured. The local 
symptoms of the aneurism were so very trifling as not to attract 
particular attention^ proving the necessity of a minute exami* 
nation of all swellings in the vicinity of large arteries. Ihm 
various instances related by Vesalius, De Haen, Palfin Har- 
derus^ Warner^ Scarpa^ Richerand^ D upuytren, &c., in which 
aneurism of the carotid has been nristaken^ even by well-in- 
formed surgeons^ for a suppurating gland, and laid open so 
freely as to give rise to instant and fatal haemorrhage^ illustrate 
the same pointy and aSbrd us striking lessons for caution in all 
cases that are in the least degree doubtful. 

llie difficulty experienced in performing the operation^ 
from the bulk of the tumour limiting the extent of the inci- 
sion^ and rendering it necessary to apply the ligature nearer to 
the heart than might otherwise have been required, where 
the vessel is so deeply seated and surrounded by important 
parts, and still more the imminent risk of immediate deadi tp 
which the patient was exposed from the rupture of the aneu- 
rism, point out the danger that would arise from delaying the 
operation. It is probable that the previous depleting and an- 
tijAlegistic treatment, and the large quantity of blood lost 
^about 100 ounces) immediately before the operation, mainly 
contributed to the successful result in this particular instance, 
en opinion which may appear in some degree borne out by the 
fiict, that there is not, as I have already remarked, any previous 
caibe on record, as far as I know, in which the application of a 
ligature to an artery so near the heart has not been followed by 
a fatal result* 



Dp. Bellingham on the Presence, 8fc. 341 



Art. XIX. — On the Frequeftcy of the Presence of the Tricho- 
cephalus Dispar in the Human Intestines, By O'B. Bel- 
lingham^ M. D., Second Surgeon to St. Vincent's Hospi- 
tal^ &c. &c. 

[Read at the Natural History Section of the British Association at the Liverpool 

Meeting, in September, 1837.] 

No point in the whole range of pathology is surrounded with 
greater difficulties or involved in greater obscurity than the origin 
of those parasitic animals whose natural and permanent habitat 
is the interior of the body of man^ and other animals ; we have 
a repugnance to allow to animals the power of creating, or (if 
I may use the expression) of secreting animal life ; yet, in what 
other way can we account for the origin of the spermatozoa of 
the human semen, and of the semen of those animals in which 
they are only periodically found, unless we allow them to be 
the product of secretion ? But in fact of secretion, and the 
manner in which it is effected, we know next to nothing; we 
learn little from an examination of the organs of secretion : no 
person could tell, d priori, that the liver must secrete bile ; or 
the kidneys, urine; or the testicles, semen ; we merely know the 
facts, but of the quo modo by which the process is effected, we 
are as much in the dark, as we are of that by which the entozose 
are first called into existence in an aninml. However, experience 
has taught us that certain causes tend to the production of these 
parasites ; we can, by keeping an animal in an unnatural condi- 
tion, cause the generation of certain species, and we know, that 
once produced, they have the power of propagating and con- 
tinuing the species even to a degree inconsistent with the health 
of the animal which nourishes them. Passing over then the 
question as to how they are originally or primarily generated^ 
as one which our present limited modes of investigation will 
probably never allow us to decide, it may be more useful to 
restrict our researches to determine, whether the mere presence 
of these animals in the intestines must of necessity be injurious. 



342 Dr. Bellingham on the Presence oftlie 

and whether they may not exist in considerable numbers even in 
the human subject without causing the slightest inconvenience. 

Many diseases were formerly supposed either to have their 
origin in^ or to be aggravated by the pretence of worms in the 
intestinal canal ; but it is well known that in almost every animal 
we examine, one or more species of these parasites is founds 
although the individual, to all appearance, enjoyed perfect 
health : from analogy, we might suppose the same to be the 
case with the human subject, which I think can be satisfactorily 
proved. 

It is not uncommon to find the taenia solium in the intestinal 
canal of individuals who never complained during their lives of 
any symptom of tape worm ; I can say the same of the oxyuris 
veitnicularis, and the trichocephalus dispar, I have found in the 
large intestines of almost every individual whom I have exa- 
mined. 

In the observations I am about to make, I shall confine 
myself to the last mentioned species, as among the entozoae, 
peculiar to the human species, it has more frequently been 
defscribed incorrectly, and it appears to be less known in this 
Country than any othef, although by many degrees the most 
comihon. In works published in England, the authors of 
which treat, either incidentally or otherwise, of the human 
entozoae, very erroneous statements are put forward respecting 
h, and my object (in this short paper) is, not to give a com- 
plete history or anatomical description of this animal, but 
merely to point out some of these inaccuracies, and to describe 
what I have myself observed. 

The genus Trichocephalus (derived from Opi^, a hairj and 
Ks^oXti, head,) is characterized by a cylindrical and elastic body, 
die anterior part being capillary, and passing abruptly into the 
thicker, by which it is distinguished from the genus Tncb'osoma, 
in which the increase is very gradual ; the mouth is orbicular, 
&e male organ a simple spiculum contained in a sheath. It 
belongs to the order Nematoidea of Rudolphi andBremser, and 



Trichoeephalus Dispar in the Human Intestines. 343 

to the division ** Vers InJtestimaux Caviiaires/' in Cuvier's 
Regne Animil?, 

The genus Trichoeephalus is not numerous in species, only 
eight being described by Rudolphi. This particular species 
(the Trichoce(di&lu8 Diapar) v?as formerly called trichuris (de^ 
rived from 0pi^, a hair, and ovgth a tail,) from the erroneous 
supposition tliat the capillary portion was the tail of the animal ;. 
it is from an inch and a half to two inches long, the capillary* 
part composing about two-thirds of its length, at the eKtremity' 
of which is its mouth. The male is smaller than the female, 
and the thicker part of its body is spirally twisted, in the female 
it is straight or nearly so ; the p^s of the male is a simple 
spiculum, contained in a sheath, the orifice of which is some- 
what bell-ejiaped. The opening, which, in the female, serves 
the purpose both of vagina and anus, is small, and situated 
dose to Ae terminatioB of the posterior extremity. 

The part of the intestinal canal which the tridiooephalus 
dispar most commonly occupies is the ceecuro, more particu- 
larly the neighbourhood of the ilio-csecal valve ; I have found 
them however through the whole tract of the colon, in the 
ileum dose to the cascum, and in the appendix vermiformis. 
We sometimes find the head of tlie animal implanted in the 
mucous membrane, lining the intestine; but this is rare ,* more 
commonly they are quite unattached, and when an opening is 
made into the cncum^ they come out in its fluid contents; 
although one of the latest writers on this subject says, '^ the 
head of the animal is commonly found implanted in the walb 
of the intestines, while the other end moves freely through the 
faeces.** 

The trichoeephalus dispar has not been so long known as 
the other parasites of the human intestines ; its discovery was 
made accidentally, in the winter of 1760 — 61, at the Anatomi- 
cal Theatre of Gottingen ; its first discoverers indeed mistook 
the male and female for distinct species. About this time, an 
epidemic (called by the writers of that period morbus mucosus) 

VOL. XII. NO. 36. 2 Y 



344 Dr. Bellingham on the Presence of the 

raged in a divwion of the French army stationed at Gottingen, 
and as these worms were very frequently found in the bodies of 
the soldiers who died of it, the conclusion come to was^ that they 
either were a cause or Uie effect of the disease ; on which (as it 
will appear that they are found in almost every individoal) 
they could have had no influence. Recently a somewhat 
similar occurrence has taken place at Naples^ the physicians to 
the Hospital d*«lla Consolatione in that city have been examin- 
ing the intestines of all those who died of cholera^ and con- 
stantly meeting with these worms in the large intestines, the 
discovery appears to have delighted them not a little, and they 
almost venture the opinion that a probable cause of this disease 
has at length been discovered.* 

I have already observed that the discoverers of this animal 
mistook its tail for its head, and named it tridiuris; however, 
afler greater care had been given to its examination^ the error 

*< * The onlj poiDti wliicb seem peoaliar^' (sajrs M . Tbibaalt,in hii aooooot oftb* 
fiOMi mortem ap|»earaooee of Uiote who died of obolera at Naples, comma nioated to 
the Rojal Aoademj of Medicine,) * and worth j of notice, are the presence of a rare 
species of worm, and of a vast quantity of thick and viscid macoi In the intestinal 
canal.* 

'* The disooverjrof this fact bj the jooag Professor Ramoglia, was at first tboagkt 
to explain the existenoe of cholera, for it had been ascertained, bejond donbt, that 
tlie appearance of this worm (which is a Terj rare one) did not precede that of 
obolera. On matorer reflection, however, the Neapolitan pbjsicians determined to 
extend their inquiries to persons not djing of cholera, and bj this sage precaotion 
thej bare thown very considerable light upon the natore of that disease. Thus, for 
example : the presence of the triohooephalos worm was determined in eighty bob- 
choleric bodies, (without exoeption,) examined between the 10th of December and 
the I St of February. They where generally in less quantity than in the bodies of 
choleric patients, hot occupied the same places, and were exactly similar. 

The results deduced by M. Tbibault from the observations of the Neapolitan 
physicians, were : 

« 1st. * That the cholera at Naples was oomplicated with one of the most exten- 
sive verminous epidemics known in history. 

'* 2od. ' That this epidemic was not confined to chderie patients, but aflfected all 
the inhabitanU of the place.' ** — Lancet, Oct, 2Sth, 1837. 



TViehocep/iaha Dupar in the Uumtm Intestines. 345 

wu corrected, and it was named trichocephalua ; it ia then not a 
little extraordiuarf that in works published in Ekigland within 
the last few years, the original error should haTe been repeated. 
In Baillie's works, edited by Wardrop, and published in the 
year 1825, we find the following; " It (the trichocephalua 
dispar) has a very long transparent tail, to their heads is 
attached a process or horn, which tliey can protrude or re- 



346 Dr. Bellinghatn on the Presence ofUte 

fully sought for it, I baTe only onoe been able to find it ; in ibis 
inttance it was lodged in tbe muetn fitting the appendix of an 
emaciated and cachectic girl.'* 

On tbe other hand, most French and German writers (who 
speak of them) state that they are very common. Botb 
Rudolph! and Bremser agree on this point Cruveilhier says : 
** in every epidemic of acute follicular enteritis, I have met 
with a greater or less number of them, and they are very often 
found in the bodies of those females who die of puerperal 
peritonitis at La Matemite ; Bremser/^ (he continues,^) '^aeys that 
they exist in almost every male subject, but I have in vain 
sought for them in a great number of cases, and rarely are they 
found in great numbers, though Rudolphi states that be has seen 
more than a thousand in the same individual. M. Gentrac of 
Bourdeaux, in an article in the Revue Medicate, says, '' tbe 
ciecum of most individuals, healthy or sick, young or ok^ 
contains almost constantly trichocephali ; it is long since I made 
this observation, I have repeated and given it publicity in my 
courses of anatomy during the last fifteen years at the School of 
Medicine in this city. Every time," (he continues,) ^* that I have 
been describing the large intestines, I have remarked as a cir- 
cumstance worthy of attention, that these organs, and particu- 
larly the ciecum, are ^constantly the receptacle, the habitual 
domicile of these perfectly innocent worms. Their presence has 
been verified in persons dying suddenly in good health, as in 
criminals ; I mu^t add however," (he continues,) ''that widiing to 
determine if, in the first periods of life, similar worms were 
found, I have searched with care for them in the intestines of 
numerous newlv bom infants, but without success." 

With a vielT to determine between the contiadtctpry state- 
ments of the English and continental pathologists, I examined 
successively the intestinal canal of twenty-nine individuals who 
died in St. Vincent's Hospital during the last twelve months, 
(of whom eleven were males and eighteen females,) and in 
twenty-six out of the twenty-nine I found a greater or less 



TVichooephtUus Ditpar in the Human Intettinet. 347 

number of these worms. The ages of these individuals varied 
much, the youngest being but eight years old, and the oldest 
upwards of seventy. The diteases which proved fatal to them 
also vsried, some died of injuriea, others of acute, and others of 
chronic diseases. In several instances I found but two or three 



348 Dr. Browne's CotUributums to 



Art. XX. — Contributions to tike Pathology of the Uterus 
By John Browne^ M. D., one of the Medical Attendants 
of St. Mark's Hospital and Dispensary, &c. 

[Read before the Surgical Society of Ireland.] 

Four specimens of different uteric lesions are here laid before 
the Society^ and as I possess a history of every case, which in 
itself presented circumstances more or less interesting, I am 
in hopes that the entire may not prove unworthy of the attention 
of this meeting. 

I shall first explain each preparation, next give a detail of 
the symptoms and treatment, and lastly make a few observations 
on such facts as appear to me worthy of notice. 

The first is a fine example of laceration of the vagina and 
uterus during parturition. The vagina is observed to have 
been extensively torn in front and laterally, almost all round, 
and nearly in a transverse direction ; pretty much about the 
place of its junction with the uterus. The peritoneum is seen 
to have been torn also in front and laterally, for about six 
inches in length, and on the lefl side the muscular tissue of the 
uterus has been implicated for an extent of three inches, but 
here the uterine cavity was not exposed, one-half of the thick- 
ness of the organ only having suffered. 

The torn peritoneum and uterus seem to have formed a 
sort of flap directed somewhat towards the lefl side, while the 
laceration of the vagina inclined more downwards and towards 
the right ; the edges of the wound are observed to be separated 
about four inches. 

Tlie other necroscopic phenomena noticed at the post mor- 
tem examination, (which took place but two hours after deatli,) 
were these : two pints of bloody fluid within the abdominal 
cavity ; the omentum gathered up into a mass and lying to the 
right side, the lower half of this membrane, the entire of the 
jejunum and ileon, the ca&cum and appendix, and about six 



the Pathology of the Uterus, 349 

inches of the commencement of the ascending colon, of a dark 
mahogany colour, as if gangrenous ; slight marks of inflamma- 
tion on the abdominal peritoneum and peritoneal covering of 
the uterus. The last named organ, contracted to about its usual 
size at the fourth month, lay superficial at the lower part of the 
abdomen, rather to the right side, having the omentum in 
contact with it ; on removing which a large, bloody coagulum, 
covering the rupture, and in contact with the peritoneum, was 
discovered. 

The particulars of the case were these : she was woman of 
middle size, sanguine temperament, fair complexion, aged thirty, 
and this was her fourth pregnancy.* Twelve hours after 
the commencement of labour she was seen by a midwife, who 
stated the pains to have been strong, the head and funis pre- 
senting. In twelve hours more, the membranes ruptured, with 
a large discharge of liquor amnii, recession of the presenting 
parts, sudden cessation of pains, and the ordinary phenomena 
of a ruptured uterus. The next morning (thirty-six hours from 
the commencement of labour) she complained of abdominal 
soreness near the pubes, with vomiting and slight haemorrhage ; 
for which symptoms she was bled from the arm to ^xviij. and 
had an enema administered. 

It was not until the fourth day of her illness, or about 
ninety-four hours from the commencement of her labour, that 
she came under my care ; she then had some of the symptoms 
of strangulated hernia, such as stercoraceous vomiting and hiccup, 
besides a general soreness and flaccidity of the abdomen ; some 
portions of the foetus were felt superficially through the abdo* 
minal coverings. The laceration was detected by the finger, 
on the lefl side of the vagina, extending upwards about two 
inches, and no part of the foetus could be felt presenting, llie 
pulse was 160, soft and very weak, and the respiration forty- 
four. 



• I am anablg to give any particultrs of her previous labonn. 



350 Dr. Browne's ContrUmlkms to 

Hopeless as the case was, I considered it to be my duty to 
perform the operation of turning, which was accordingly ef- 
fected in the usual way^ and well sustained by the patient, who, 
although the pulse ceased, survived about four hours. 

The distance between the pubes and sacral promontory was 
less than usual, so that the passage of the hand was impeded. 
The cavity of the uterus was large, relaxed, and filled with co- 
agula, in the midst of which was found the placenta detached. 
A discharge of half a pint of venous blood followed the extrac- 
tion, and several folds of intestine were felt towards the fundus, 
both before and after the operation. 

The foetus had been dead several hours, and was much de- 
composed, having been probably deprived of life, soon afW 
labour commenced, by pressure upon the funis. It appeared to 
have presented naturally with the vertex, but the left lower 
extremity at this time had passed through the rent ; among the 
intestines, there was no perceptible uterine action. 

This case adds but another to the many already on record 
of one of the most lamentable casualties to which the human 
female is liable during the whole period of her parturition. 
The deplorable ignorance of the attending midwife is much to 
be regretted.* Had she called in medical assistance at first, 

* 1 have ofteo thought that much miichief might be preveoted by an im- 
prored system in the education of our midwives, similar to that adopted in France 
and Germany. They are, in those countries, of a better clans in society, taught 
their profession more extensively and carefully, and commence their studies at a 
period (fifteen or sixteen years) when the mind is ripe for learning and svisceptiUt 
of retaining H. I shall never forget the aurpriae and gratifioatipn which I exp»- 
rienced whilst going through the obstetric wards at Viennfli, on being addressed in 
French by a modest and elegant young female, (one of the midwifery pupils,) who 
politely explained the economy of the department ; my imperfect knowledge of 
the German language preventing me from comprehending Professor Klein in his 
▼emacular tongue. Could our national customs permit us to substitute intelligent 
and educated young Udiet for itupid and ignorant old nungi, a great natioMl 
benefit, I have no doubt, would be achieved. Dr. Granville laments the eril of 
which I complain, and gives some frightful examples, but without suggesting, as 
it seems to me, a sufficient remedy. (See his Report of the Practice of Mid- 
wifery at the Westminister Dispensary, page 201,) 



the Pathology of the Uterus. 351 

tbe accident might hafe been prevented ; and afler the occur- 
rence of the rupture, the delivery of the foetus and replacement 
of the intestines would have given the woman a much better 
chance of her life than she ultimately had, by the removal of 
the two principal causes of the violent abdominal inflammation 
discovered after death, namely, tbe contact of a foreign solid 
with the delicate peritoneal covering of the intestines, and the 
constriction of so many of their folds by the edges of the lace- 
rated opening. As long too as the uterus was prevented from 
contracting, more or less of bloody effusion was allowed to go 
on, which must necessarily have added to the inflammation. 
The laceration was not, it is probable, so extensive originally as 
it here appears, but must have been materially augmented by 
the continuance of a great portion of the foetus between its lips 
for the long period of seventy hours. 

Pelvic deformity appears to have contributed to produce 
this laceration, and to have been of a comparatively recent de- 
velopment, as it is probable that had any of her previous 
labours been difficult, she would have mentioned the circum- 
stance, which it is believed she did not. Such deformities 
some authors suppose to be a frequent cause of this accident.* 
The phenomena, well marked, were followed by those of in- 
flammation, to which succeeded symptoms of intestinal stran- 
gulation. 

Writers state the fatal ify in uterine and vaginal lacerations, 
to depend on three causes, viz. collapse, haemorrhage, and in- 
flammation ;t of these the last appears to be the most general,^ 



* RoborlsoQ ia Edinburgh Medical and Surgical Journal, vol. xlii. p. 49. 

t Ingleby ia Dublin Medical Journal, No. XXIV. p. 451. — ^Maygrier L'Art 
Des AccouchemeDs, torn. ii. p. 271, &c. 

% ** In every case which I have seen, the inleflUnet were chiefly affected, being 
much ioflamed." — Burns' Midwifery, p. 405. " If the patient survive the more 
immediate effect of the accident, tymptorot of abdominal or peritoneal iniam- 
mation presently supervene, and are gradually progressive." — Uamsbotuav's 
Practice Obarvationi in Midmf§ry, Part 1, p. 387. 

VOL. XII. NO. 36. 2 z 



352 Dr. Browne's Contributions to 

and most alarming, and as such should be the chief object ofour 
attention. 

I shall not occupy the time of the Society by insisting on the 
propriety of immediate delivery, such a practice being, I be- 
lieve, generally approved of at the present day ; but I do think 
it expedient to say a word or two on the necessity of the subse- 
quent employment of bleeding, both topically and generally, as 
an idea has prevailed that such depletions are often uncalled 
for, and may, therefore, safely be dispensed with.* 

On referring to Doctor Collinses valuable observations,t I 
find that two cases which recovered had, the one six dozen, and 
the ottier nine dozen of leeches applied to the abdomen ; and 
that six other cases which were similarly treated, (two of 
them being also bled from the wrm for convulsions,) held out to 
a longer period than the subjects of such untoward accidents 
usually do^ some of them dying of accidental complications, as 
lumbar abscess, &c. In Dr. Ramsbotham's Observations,^ 
three eases of recovery are given, in two of which venesection, 
and in the third leeclies to the abdomen were employed ; in 
Doctor Frizell's case§ bleeding from the arm was used, and the 
subject of the present history probably had her life prolonged 
by a similar measure. 

Truth, however, compels me to state that recoveries have 
taken place under opposite circumstances, or without the em-> 
ployment of such measures ;|| but in such instances the ^^^p- 

* "There is certainly little chance of any person lunriving a rupture of the 
uteras ; it therefore might be doubted whether it would be more eligible to lufler 
the patient to die without giving her further trouble," &c. — Dbhxam '• Practice 
of Midwifery, p. 328, 4to. 

t Practical Treatise on Midwifery, p. 248. 

t Opui ciUtum, Part 2, pages 484 to 498. 

$ Dublin Medical Transactions, vol. ii. p. 16. 

I Duncan's Annals of Medicine, vol. iii. p. 277. M'KeoTer in Dublin 
Medical Transactions, vol. iii. p. 280. Memoirs Medical Society London, 
Tol. iv. p. 253, &c. LabaU in Dublin Medical and Physical Assays, toI. i. 
p. 348. 



the Pathology of the Uterus, 353 

toms have been unaccountably^ mild ; and I merely, wish to 
add my conviction to that of more experienced practitioners^ 
that, after delivery, to be eSeeted in the manner best suited to 
the circumstances of the case^ the chief danger to the patient, in 
the majority of instances, will arise from abdominal inflamma- 
tion ; and that the more promptly such symptoms are met, the 
greater chance will be afforded to the patient of recovery. 

The next preparation displays an extensive ulceration of 
the uterus ; the cervix and the os uteri have been completely 
destroyed, and the ulcer occupies half the remaining portion of 
the organ. Inferiorly it is seen to extend one-third upon the 
vagina all round, being at one part quite superficial, as if a por- 
tion of the lining membrane had been but just abraded. 

Tlie surface of this ulcer had the white, yellow-greenish as- 
pect of a scrofulous sore, and it discharged a copious thick 
curdy secretion : to the touch it gave the sensation of an irregu- 
lar border, extremely soft, and easily breaking down. 

The uterus (at least what remains of it) is seen enlarged to 
twice the natural size, or to about its ordinary bulk at the se- 
cond month of impregnation. Its upper third retained a natu- 
ral consistence, but the middle was somewhat firmer than is 
usual ; the vascularity of this portion of the organ was much in- 
creased, and its texture, on being cut into, resembled that of an 
impregnated uterus, the walls being from half an inch to three- 
quarters in thickness. There was also a distinct line of demar- 
cation between this part and the superior or more healthy por- 
tion of the organ, which occupied the entire thickness of the 
walls. When the finger was passed into the vagina, it readily 
entered the uterus through a large relaxed opening, surrounded 
by a soft irregulai border. 

In regard to the uterine appendages, the tubes and ovaries 
were nearly normal, the latter, however, of a size less than usual, 
and a small tubercle was devoloped in the left. The disease 
had not extended either to the bladder or rectum. 

The abdominal viscera were healthy, with the exception of 



354 Dr. Browne's Contributions to 

the liver^ upon the convex surfaces of which marks of rormer 
inflammation were evident 

The thorax^ unfortunately, was not examined. 

The body was plump and loaded with fat, which also occu- 
pied the abdominal cavity. The left lower extremity and cor- 
responding labium pudendi were anasarcous. 

The subject of these observations was aged 40» of middle 
size, and stout make, and the mother of eight children ; she 
had been attacked six months before with hsemorrhagia, which 
continued profusely and almost daily, for five months, when it 
ceased, and was followed by the anasarca and great exhaustion, 
but without pain at any period. 

When I saw her she was moribund, her countenance ane- 
mic, like that of a person who had lost a large quantity of blood, 
she spoke with difficulty, appeared greatly exhausted, and sur- 
vived but four hours. Under such circumstances no vaginal 
examination was instituted. 

What was the nature of this sore ? Scrofulous, I reply, well 
marked ! indeed so clearly characterized, as to be beyond reach 
of being confounded with any other species of ulceration ! ! It 
may be said that it was nothing more than an instance of die 
corroding ulcer so well described by Dr. Baillie* and Sir 
Charley Clarke ;t I admit a resemblance in some respects, but 
there are differences in others ii at the same time that I object 
to the employment of the term *^ corroding ulcer" altogether, 
as both unscientific and inexpressive. What ulcer is there 
"i^hich is not corroding? in fact all ulcerations are nothing more 
in common language, than corrosions of the parts which they 



* Morbid Anatomy, vol. ii. p. 337. 

f Diseases of Females, vol. ii. p. 185. 

t The time of life of the patient, the extent of the destroction of partf, aad the 
profaaeneta of the hsmorbage, coincide with Sir Charlea Clarke's deaoriptioa ; hot 
there nerer was anj homing pain in the present instance, " as if a hoi coal wO* 
within," and we find an enlargement and thickening of parts, of which he doesoo' 
admit the existence. 



J 



t/ie PcUhotogtj of the Uterus. 3.55 

attack. I can conceive a corroding ulcer of tike uterus to be 
scrorulous, syphilitic, or cancerous in its nature, without losing 
its characteristic peculiarity, but should be glad to see a more 
physiological designation adopted for it. 

Scrofula in (he form of ulceration has seldom been observed 



356 Dr. Browne's Contributions to 

scrofula in several of our tissues, at one and the same time, af- 
ford but little encouragement to our hopes of cure in such 
cases ; nevertheless the usual constitutional treatment, together 
with the local employment of the preparations of iodine, might 
occasionally be found advantageous, and therefore would at 
least deserve a trial.* 

The third preparation displays an example of the large, 
white, fleshy tubercle or fibrous tumour of the uterus, combined 
with a polypous growth from the inner surface of the fundus. 
The uterus is seen to be generally enlarged, probably as much 
so as at the fourth month of pregnancy, and this enlarge- 
ment is found to depend on hypertrophy of its tissue above 
and in front, from the development in those situations of 
fibrous matter. On cutting through this enlarged part a con- 
siderable polypous growth was discovered, irregularly lobulated 
and fissured, and growing, by a broad basis, from the fundus 
and one side of the body of the uterus. This tumour is softer 
and less firm tlian the general uterine growth, though they may 
be nevertheless, identical in structure. 

As this case did not occur in my own practice, I am unable 
to give a very accurate account of it ; thus much, however, I 
can state, the woman was advanced in life, say fifty years of 
age, and had laboured under a morbid growth, impeding 
the due evacuation of the bladder and rectum, for at least 
two years. On examination per vaginam, the os uteri was not 
to be felt, being supposed to have beeen displaced by^ a tumour 



* Since Uiese remarkg were pat togeUier I have discovered Uiree or four pre- 
piratiooi ID our maaeom, of scrofula affectiag Uie uterus or its appendages ; in the 
most conspicuous of these the disease appears in the form of tumours filled with 
soit matter situated in the uterine substance, and combined with hepatic disease of 
a like nature, in the same subject ; in the others the tubes or ovaries are occupied 
by similar productions. In the same collection is to be seen the utenis of a Bar- 
bery ape, occupied almost entirelj bjr a large soflened tubercle ; and similar affec- 
tions have been noticed, along with phthisis and other forms of scrofula, in several 
of the other varieties of the quadromani. 



the Pathology of the Uterus. 357 

• 

which had descended between the bladder and rectum ; true 
it was such a tumour existed, but it was not at the time dis- 
covered to be incorporated with the uterus, but on the con- 
trary considered as a distinct growth, probably capable of re- 
moval by a surgical operation ; the woman, however, gradually 
declined, and died before jthe operation was decided on. 

At the post mortem examination '^ the uterus was found 
retroverted and pushed down, so as to press on the perineum, 
and had formed adhesions with the surrounding parts ; its bulk 
was nearly that of the head of a full grown foetus, its walls were 
thickened to about three inches at the fundus, and it contained 
a dark-coloured fleshy excrescence of the polypous kind, but 
with a broader base and irregular ; one of the ovaria was oc- 
cupied by a small fibrous tumour." 

I consider this to be an interesting specimen of morbid 
uterine structure, in two points of view : first, as an example of 
the fibrous growth from two distinct portions of the uterus at 
the same time ; and secondly, as an instance of retroversion in- 
duced by causes independent of pregnancy. Authors* have 
usually confined the fibrous growths of the uterus to three situ- 
ations, viz. the external surface under the peritoneum, the in- 
ternal surface beneath the lining membrane, and the substance 
of the organ between the muscular fibres j or they may occupy 
all or any one or two of these positions together, as in the case 
before us. Most generally their seat is confined to some one 
place, perhaps we might say that those growing from the inner 
surface are most frequently met with, and it is fortunate that 
such is the case, as they are necessarily more within reach than 
when developed in other situations. 

A question here arises, are we, in cases where fibrous tu- 
mours (or polypi), growing from the inner surface of the uterus. 



* DopQjtreo, Le^ns Oralef de Clinique Chirargicale, tome iii. p. 454. BoiTin 
et Doges Mtladits de llJtenu et de set Anaex^es, tome i. p. 801. Desaalt, 
(Enrres CbiraiYioiles par Phil. Jos. Rons, tomt iii. p. S78, ke* 



358 Dr. Browne's Conltibulions to 

produce such symptoms as ta demand an operation, but are, at 
the same time, complicated with similar growths on the outer 
surface or in the uterine substance, to take the ordinary mea- 
sures for their removal ; or are we not to interfere, on the prin- 
ciple that it is useless to remove disease from one part, when it 
must necessarily soon appear again in another ? 

On this subject some of our highest authorities are at issue, 
for while the late Doctor Gooch* and Professor Rouxf advo- 
cated the latter practice, the former was clearly and strenuously 
insisted on by the late Baron Dupuytren,:): one of the highest 
authorities, it must be allowed; on this as well as most other 
surgical subjects. The reasons which the Baron assigns I con- 
sider to be cogent; " you excise such polypi,*' says he, " because 
you thereby remove the local inconveniences arising from their 
bulk, pressure, discharge, &c., and prevent their possible dege- 
neration into cancer, to which they are very liable ; and because 
in the other situations they are often extremely indolent, of a 
very slow growth, becoming sometimes bony or cartilaginous, 
and seldom shortening life." 

Let us now turn to the case as one of retroversion. To 
produce this displacement writers appear to be agreed in as- 
signing one necessary condition, viz., that of enlargement,§ to 
which some|| add another, that of relaxation of the ligaments. 
Such enlai^ment must take place to a certain extent, and not 
be in excess.^ The production of retroversion by uterine polypi 



* DiieMes of Women, p. 279. 

f (fiavres Cbirarg. de Deiaalt par Ph. J. Roox, toiae iii. p. S8'2. 

X Le9ons Orales, tome iii. p. 564. 

§ Borns' Principles of Midwifery, p. 249. 

II Boivin et T)ufr6s Maladies de I'Uleras, Arc, tome i. p. 137. 

% "The retroversion of the nteros bas generally ocearred ftboot tlie third 
month of pregnancy, and aometiraea after delivery ; it may likewise happen when 
the atenis i8,/roni any cause, enlarged to the size itacqoires aboat the third month 
of pregnancy, bnt not with such facility as in the pregnant state, because the enlarge- 
ment is then chiefly at the fandos. If the ateros be but littU enlarged, or if it be 



the Pathology of the Uterus. 359 

has been noticed by Madame Boivin* and Sir Charles Clarke^f 
but I am^ in the present instance, more disposed t attribute 
the occurrence to the fibrous tumour of the body, particularly 
as it was unusually dense and heavy. 

Other sorts of enlargements of the cervix and body of the 
uterus, whether inflammatory or not,^ have been known to give 
rise to retroversion, such as those produced more immediately 
by ex{x}sure to cold and imprudences of various kinds, whether 
some time after delivery before the uterus has returned to its 
ordinary dimensions, or as a consequence of suddenly sup- 
pressed menstruation, inducing, perhaps, what may be termed 
a temporary hypertrophy of this part of the reproductive sys* 
tem.| Certain states of the neighbouring organs, as the bladder 
and rectum, may also act as exciting causes, from the mechanical 
pressure to which they give rise.H 

In most cases of retroversion unconnected with pregnancy, 
it will not be necessary to adopt manual efforts for replacement, 
the removal of the exciting causes, and attention to the condition 
of the neighbouring hollow viscera being sufficient ;ir but should 

enlarged heyimd a ctrtam $ixe, it oanoot well be retroverted : for, in the first 
eeee, sbonld the cause of a retroversion e&ist, the weight of the faodas would be 
wanting to produce it ; and in the latter the ntems would be raised above the 
proileotion of the sacrom and supported bj Uie spine«**— DimiAN'f Midwtfgnf, 
p. 06, 4to edition. 

* Opos citatam, tome i. p. 1S8. 

t Diseases of Females, vol. i. p. 273. | Pearson on Cancer, p. 118. 

§ See an interesting paper bj Mr. Robertson in Edinburgh Medical and Snr* 
gtoal Joomal, vol. xviii. p. 520. 

I A ease of retrorersion AUal from obstipation and Tomiting is given bj Dr. 
Maroet in Sir A. Cooper's work on Hernia, vol. U. p. 08. 

% '* But in the onimpregnated state the sjmptoms never arrive at this melan- 
choly height, and for this plain reason that the uterus in such cases never acquires 
so much size as to entirelj and intimatelj oecopj the lower portion of the pelvis, 
and conseqnentlj cannot completelj obliterate the urinal and fecal canals.*' — 
Dbwees' Euayt on varinu Subfittt eonntcted with Midwiftfy, p. SOS, 

VOL. XIT. NO. S6. 3 A 



360 Dn Browne's Contributions to 

such measures be thought proper they ought at once be takeiQ 
as the uterus may become adherent Hi its unnatural position^ as 
occurred in the present instance, and in another related by 
Dewees.* 

I am not aware that a retroverted uterus has hitherto been 
in danger of removal by operation, but can conceive the adopr 
tion of such a measure with impunity to the patient, (particu* 
larly if beyond the period of child bearing,) as has been done 
in certain cases of inverted uterus mistaken for polypi ;t at the 
same time that I would not go so far as to recommend such a 
practice unless under very peculiar circumstances. 

The next preparation exhibits a portion of a fibrous poly-^ 
pus removed from the cervix uteri, possessing an unusual de* 
gree of vascularity, so as to endanger the life of the patient, 
at the time of its removal, and thus becoming worthy of our 
notice. 

On the cut surface may be observed the orifices of two 
arteries, the larger nearly the size of a crow quill, being the 
sources which furnished the blood. 

Excision by means of a large scalpel was the mode of re- 
moval employed, the forceps of Museux being used at the same 
time to bring down the parts as far as might be. A most pro* 
fuse haemorrhage instantly followed, which was so alarming aa 
to demand the instant insertion of a plug in the vagina ; an old 
sod silk handkerchief was used with the desired effect ; this, iiv 
half an.hour, was removed, but the bleeding instantly recurring 
with unabated violence, a fresh plug was inserted with the same 
eflect in promptly arresting it. 

The subject of the case was a stout woman, aged thirty -nine, 
unmarried, who had been employed as a farmer's servant — 
Efght years before she had had menorrhagia, lasting pretty 
constantly for two years, and succeeded, three years afterwards. 



* Deweet Etsajrson Tarioos SobjecU conneoted wiUi Midwifery, p. SOS. 
t Johnson, b Dablio Hoapittl Reports, fol. iii. p. 481. 



the Pathology of the Uterus. 361 

by retenUon of urine, followed by paralysis of the bladder and 
amenorrhoea. About a year since I examined per vaginam, 
when there appeared to be mere uterine enlargement with a 
partial closure of the os uteri, and it was not for several months 
afterwards that the vaginal tumour became perceptible^ during 
a sudden exertion in lifting a weight 

When this woman was admitted into Saint Mark's Hospi- 
tal^ in September last, the tumour had descended to within two 
inches of the orificium externum^ its upper part being attached 
by a broad semicircular base to the left side and front of the 
cervix ; the os uteri appeared to be dilated, and considerable 
Moody discharge followed all examinations of the tumour, 
although no such appearances were observed at other times. 

She had also, at this period, and of three years' standing, 
a firm moveable tumour, about the size of a small orange, on the 
right side of the abdomen, half way between the spine of the 
ilium and the umbilicus, occasionally the source of much pain 
and sufiering ; and a small soft polypus growing from the left 
side of the vagina. 

' At the time of the operation, probably from the existence 
of adhesions in connexion with the abdominal tumour, the 
cervix uteri could not be drawn down by the hooks, as far as 
could be wished ; from which cause, as well as the unexpected 
haemorrhage, little more than one-half of the tumour could be 
removed. The existence of disease in the body of the uterus 
or in the ovarium being also demonstrable, and the perfect re- 
covery of the case, under such circumstances problematical, no 
farther attempts to excise the remainder of the tumour were 
considered to be advisable. 

The vaginal polypus (which appeared of a cellular na- 
ture) was torn away, and ^he was dismissed considerably re- 
lieved. 

In this case we had the co-existence of the cellular and 
fibrous kinds of polypi, both growing together from the same 
species of mucous membrane ; and the principal tumour appears 



362 Dr. Browne's Contributions to 

to have been attached immediately within the os tiiic», one of 
the lips of which had become elongated. Whether a second 
polypus was developed at the same time within the uterine 
cavity, as has sometimes occurred,* I shall not pretend to say ; 
neither did I consider myself justified to make particular exa- 
mination on the subject, both from the hemorrhagic disposi- 
tion which existed^ and from the relief which bad been already 
experienced. 

The presence of the abdominal tumour also complicated 
matters ; whether it was a pediculated fibrous growth from the 
body of the uterus, or an ovarian tumour, could not be det^- 
mined, and although the woman was exceedingly desirous to 
submit to any operation for its removal, and notwithstanding 
the encouragement held out by the several instances of suc- 
cessful result detailed in various periodicals ;t I did not conn- 
der that her sufferings from this cause were suflScient in de- 
gree to authorize me to lay open a serous cavity of such extent^ 
and so disposed to inflammation, as the peritoneum.} 

This is but the fourth case of alarming haemorrhagie super- 
vening on the excision of a fibrous polypus, which I have been 
able to find on record. The first is stated to have occurred in 
the olden time to Zacutus, and to have t>roved fatal to his pa- 
tient ; but I have not met the details : the two others are re- 
corded by Dupuytren; § in these the bleeding was speedily 
stopped by the ^ tampon," but one of the individuals perished 
on the twenty-fiflh day of peritonitis. || I firmly believe that our 

* DopnjtTMi, Le^oaa Oralet, tome iii. p. 43:1. 

f Bolectio Rep. toI. tii. p. 242. Ediobwgh Mediotl ud Surgical Jooraal, 
▼ol. ZTiii. p. 633. and toI. xxiu p. 247. 

t Since Uiis paper wai written, the woman %u died* bot whether of her old cos- 
plaint or not, I ooold not aaoertain« 

$ Le^one Orales,tome iii. p. 450. 

I " A loaa of blood** (obierres the Baron, talking of soma of theteoasea) " mm 
or lesa coniiderable, is alwajs aaefol after these kinds of operatione, and renders 
moch less imminent the consecntive inflamnatorj accidents to which the patients 



the Pathology of the Uterus. 363 

patient would have run the greatest risk under the employment 
of ordinary measures. 

Polypi have occasionally been observed to be highly vascu- 
lar, nay, large blood-vessels have been seen ramifying on their 
surfaces,* such facts, however,t are no proofs that their pedi- 
cles, when divided, may furnish blood, as that is generally not 
the case ; bnt they have their utility, as they point out to us, at 
least, that the division of the pedicle of the polypn» is not aU 
ways an operation of such little importance as some practition- 
ers affirm.} 

HflBmorrliage may also occur under other circumstancesyhither- 
to not much noticed, viz. at the period of the falling off of the 
ligature, when used for the constriction of polypi ; thus M. 
Dubois gives us the astounding information, that at such a pe- 
riod he has many times seen blood issue forth in abundance, 
and has lost in this way many petients.§ I am happy to say, 
that I am not aware of the occurrence of any such cases in this 
country. 

So much difference of ofnnion exists as to the greater or 
lesser eligibility of the two methods generally employed for the 
removal of uterine polypi, vis. excision fmd die ligature, that 
I shall not enter into the question, but simply exjxcees my con- 
viction, that both methods occasionally prove fatal, and .much 
more freqnently than has been supposed, more especially when 
the tumours are of a large size ; such fatality appearing to arise 

■re ezposed."^L«foii« Oraki, tome iiu p. 450. Bet oo his own ibewing raeh 
Mlaterj discherget hare seldom ocoarred to him, saoh poljpi as be hid ezoised in 
f enerml effording bot a Terj few drops of blood. 

f Sariard (Obs. Chir* Obs. SO) mentions one with two arteries and two Teins ; 
the Joomal de Medeoine, tome xxiz. 1768, notices a second with two arteries and 
one rein ; and a third, with pnlsations in the pedicle, is deseribed in Hem. de 
rAondemie de Chimrg., tome iil. p. S9ft» 4to.) 

t Lemons Otales, tome iiL p. 459. ^ 

X Boivin, Maladies de TUteras, tome i. p.S40. 

} Dictionseire des Sciences Medicales, Art Poljpes. 



364 Dr. Griffin's Mt^ical ProUms. 

principally from three causes, viz. iniatsmaiioii of the pdvic 
viscera, uterine phlebitis, and low fever. 

The pressure of a large polypus upon the parts filling the 
p^vic outlet, often produces a chronic inflammation of the 
uterus, small intestines, &c., which only requires the additional 
irritation of an operation to develope a more acute and fatal form 
of it : under such circumstances a mere manual examination of 
a* polypus made more forcibly than usual, has determined a 
fotal inflammation.* Uterine phlebitis, in consequence of ope- 
rations upon polypi, is more rare, but still fatal cases are not 
wanting. By the term low fever, I understand, that state of 
prostration and exhaustion, preceded by rigor, into which pa-t 
tients with large, sloughy suppurating polypi are apt to fall, and 
of which they die at the end of six or eight days: sometimes 
marks of inflammation are found, sometimes they are absent^ 
the patients appearing to be carried ofi* imder the operation of 
an animal pioson. 

The doctrine of the absorption of pus as a cause of fever 
will not, I know, be generally admitted, nor have I any thing 
new to offer on the subject, I therefore refer my readers to 
Baron Dupuytren's valuable monograph on fibrous tumours, in 
which he tells us of twelve or fourteen patients actually poisoned 
by putrid absorption.f 



Art. mU.— Medical Problems. By William Griffin, M.D., 

Limerick. 

(^Continued from Vol, XL p. 17.) 

Is Laryngismus Stridulus, or the crowing disease, a spasmodic 
or paralytic affection ? 

Before entering on the discussion proposed in the foregoing 
problem, or again opening a question which seems to have 



♦ Le^DS Oralef , tome iii. p. 494. f Ibid, p. 559. 



Dr. Griffin's Medical Problems, 365. 

been almost decided by the very ingenious and clever work of 
the late Dr. Ley, it may be of use to give a sketch of the few 
cases of laryngismus stridulus which first attracted my atten- 
tion to the subject 

The complaint does not appear to be so remarkably rare of 
occurrence, as was imagined when it first came to be accu* 
rately described by medical writers. The cases I shall relate 
all happened within the last two years in my own practice, and 
die great majority of the profession who have written on the 
diseases of infants latterly, evince a familiar acquaintance with 
it The fact that an affection, I might almost say so common^ 
diould have been completely overlooked by almost all the* 
eminent men of past times, is sufficiently mortifying, whether 
looked upon as illustrative of the difficulty of the diagnosis, or. 
a general inaccuracy of observation, 

I shall first describe two cases in which the phenomena of 
the crowing disease formed but a minor or less important part 
of the whole affection. They are curious as illustrations of a 
complaint, which, I believe, has not even yet been noticed by 
any medical writer, and which might, perhaps, to distinguish it 
irom the crowing disease, be appropriately called the crowing 
apoplexy of infolds. 

An infantof rather a spare and puny frame, although healthy 
looking in its countenance, on the eleventh day after birth, 
was affected with bowel complaint. The motions were very 
fluid ; of a light yellow colour, and there were about six in the 
course of the day. It got a little chalk powder from the nurse 
at night, and next morning a drop of laudanum. The motions 
were less frequent, though still loose, and the child did not look 
well. It had been fed on milk and water, and a little prepared 
barley from its birth, the flatness of its mother's nipples prevent* 
ing its obtaining much nourishment at the breast ; and it was 
now suckled by a woman whose child was twelve months' old, 
but perfectly healthy, while they were waiting to procure a 
younger nurse. In the evening, however, it was seised sud*^ 



36& ' Dr. Griffin's Medical PtoUemi. 

denlj, BB if with sufibcatioii, losing its breath, and beoomit^ 
first pallidj afterwards dark or purplish in the faoe, and finally, 
when all respiration was suspended, of a deathlike hue. There 
was a stiflTening of the frame and twitching about the mouth, and 
the timmbs were drawn into the palms of the hands; but there 
was no convulsion of the body or extremities. After a longer 
or shorter interval the breath was recovered by ga^M, which 
were accompanied by a crowing sound, that became louder 
after a time, so as sometimes nearly to resemble hiccup. This 
crowing again gi^dually died away, and the respiration became 
easier, but always recurred on the approach of another fit, and 
continued until the breath was lost ; when the child, as in the 
first instance, grew dark for a moment or two, and then pale 
and death-like. It w^s indeed sometimes impossible in these 
intervals of suspended respiration, which recurred frequendy, ta 
say whether the child was living or dead. It lay cold, white, 
breathless, and without sign of animation, often for three or 
nearly four minutes, counted by a watch, and then recovered 
with a faint gasp, followed by the crowing. The intervals be-> 
tween the fits of suspended respiration were seldom longer than 
half an hour, although they occasionally extended to an hour or 
more. The crowing sometimes continued throughout the in- 
terval, at others abated for a little. From the first moment of 
the attack the infant never recovered its consciousness, the pu- 
pils seemed fixed, the eyes senseless, and all power of degluti- 
tion was lost Whenever a teaspoonful of liquid was given it 
remained in the mouth or flowed out at the comers, or if it went 
back to the larynx it obstructed the breathing, and brought on 
the fit of suspended respiration. The only approach to sensi- 
bility observable at any time was in the slight motion of the 
lips, which were sometimes seen to work as in the action of suck- 
ing. There was rarely, when the fit of suffocation commenced, 
a slight convulsion or twitching of the muscles of Uie foce, which, 
however, never lasted longer than the blackness or darkness, 
and seemed in fact a struggling for breath ; but as the case 



Dr. GriflSn's Medical Problems. 367 

became protracted^ although the crowing in the intervals con- 
tinued as loud as before, no darkening of the face or writhing 
of the features preceded the 6t. 

As the power of swallowing was gone^ the treatment was 
confined to injections^ stimulating liniments to the spine and 
stomachy and the warm bath. The first consisted of starch and 
assafoetida. Turpentine was afterwards used^ and when these 
means seemed unavailing^ laudanum was administered. The 
injections were sometimes retained for half an hour, but usually 
came away soon, and in no case had any perceptible influence in 
preventing the fits^ although as much as eight drops of lauda-* 
num were given in this way. The bath at first seemed of ser- 
vice, and prolonged the interval, but after some repetitions 
lost its effect. A blister, which was applied to the back of 
the neck, was equally fruitless, and after an illness of about 
forty hours' duration, the poor little suflTerer ceased to breathe 
any more. 

CasbII. — ^Afine, round-limbed, healthy-looking boy was bom 
after a favourable labour of about six hours' duration. He got 
castor oil, as infants usually do, and on the morning after I was 
requested by the nurse to inspect the motions, which were very 
green ; the one she shewed me had the appearance of chopped 
spinach. I directed a grain of calomel to be given, and if it 
did not move the bowels freely, the oil in the morning. Next 
day the motions still continuing green, though less so than be- 
fore, the calomel was repeated. On the fourth day the bowels 
were much better, and on the fifth the evacuations seemed to 
be of the ordinary character. The child during this time got 
nothing except the breast, and (the mother not being able to 
nurse long nor often on account of sore nipples) a little pre- 
pared barley, or milk and water. It appeared to thrive, and did 
not lose its plumpness, but the mother afterwards informed me 
it used to start frequently with a cry or scream out of its sleep^ 
in a way she had never observed with her first child, who vras 
alive and well. After this s^idden start or scream it usually 

VOL. XII. NO. 36. 3 B 



368 Dr. GrifBn's Medical Problems. 

fell asleep immediately. On the evening of the tenth day^ 
ifvhen my attendance had terminated, the child was attacked 
with slight complaint in the bowels^ for which it got a little 
chalk mixture. The bowels were moved five or six times during 
the night, not very profusely ; and the evacuations were of a pale 
yellow colour. At eight o'clock the next morning I was sum- 
moned hastily to visit it, and on entering the room, to my utter 
consternation, I found it gasping, after a fit of breathlessness, 
precisely similar to that described in the former case, and fol- 
lowed by the same crowing noise in inspiration. It was per- 
fectly insensible; the pupils of the eyes were natural in their 
appearance, but sluggish in their movements; the power of 
swallowing was gone ; the thumbs were bent into the palms 
of the hands; the surface was pale and cold; the impulse 
of the heart and the pulse at the wrist were feeble. Tlie fit 
of suspended respiration occurred at intervals of perhaps twenty 
minutes, though they were sometimes longer. The child's 
countenance did not darken in the fit as in the other case, it be- 
came instantly pale on losing its breath ; the lips and even the 
tongue were cold, and when I put back my finger to the pha- 
rynx, to ascertain whether I could by the touch excite the ac- 
tion of swallowing, I found the parts motionless. The crowing 
continued almost through the whole of the interval, and, if it 
did cease, it always recurred on the approach of the fit On 
one occasion, after the warm bath, it seemed to subside into a 
breathing slightly stertorous, which did not at all occur in the 
case of the former child. There was, however, once or twlce^ 
in the course of the day, the same working or sucking motion 
of the lips which I noticed in that case, indicating some faint 
approach to sensibility. 

The treatment of this little patient differed in no respect 
from that employed for the former infant, except that no lauda- 
num was administered, and it was equally unsuccessful. If it 
could be said that anything gave the least relief, it was the 
warm b&th. A blister to the nape of tlie neck and vertex was 



Dr. Griffin's Medical Problems. 369 

applied early^ but before it could have had any effect^ the little 
sufferer expired, having struggled altogether only six hours 
against the disease. 

On examining the body of the first infant no appearance of 
disease was observable in the heart, lungs, or bowels. On 
opening the head there was excessive difficulty in detaching 
the skull from the dura mater, and as soon as it was removed 
the hemispheres fell asunder in a diffluent or pultaceous mass, 
so that it was impossible to make any regular examination. 
Having removed the gelatinous mass of brain and cerebellum, 
the medulla oblongata and spinal cord were found of healthy 
consistence. 

I now thought I had a clue to the explanation of the symp* 
toms. There appeared to be here sufficient disorganization to 
account at least for the insensibility, and attach probability to 
the supposition that the crowing respiration was dependent on 
some affection of the brain. Billard speaks of such general ramol- 
lissement,as of\en occurring immediately after birth, and mentions 
that it is then more considerable and extensive than at any other 
period of life. He thinks it probable that it sometimes begins 
even before birth. I do not know what the attending symptoms 
were, but in ten such instances in which the softening extended to 
the whole of the spinal cord, he relates, that the respiration 
was laborious and imperfect, the limbs flaccid and motionless, 
and the pulsations of the heart scarcely perceptible. These 
symptoms were all absent in the case of the infant which I have 
detailed, it would seem, because there was no lesion or disorga- 
nization of the spinal cord or medulla oblongata; but the func- 
tions of the hemispheres and of the cerebellum were altogether 
suspended, as the ramollissement of these parts would lead one 
to expect. 

There could, however, be no stronger prool*, that identity 
of functional derangement is no evidence of the identity of the 
lesion which produces it, than appeared on examining the body 
of the second infant, the symptoms of whose disease so closely 



370 Dr. Griffin's Medical Problems. 

resembled those of the first. The brain seemed perfectly 
healthy^ and there was no sign of disease in any other organ 
that I could detect The examination in either case was a 
very hurried one^ which precluded any examination of the state 
of the eighth pair of nerves, or recurrents, or of the bronchial 
glands. Indeed it did not occur to me as a matter of any im- 
portance to make the examination at the time, as I thought it 
utterly improbable there could be any scrofulous enlargement 
•of these parts immediately after birth. There certainly was no 
perceptible enlargement of the glaudulse concatinatas, or other 
glands in the neck. The thoracic and abdominal viscera were 
also in this case healthy. I do not know, however, what im- 
portance, if any, to attach to one circumstance : the cardiac ori- 
fice of the stomach was found plugged up with a firm coagulum 
of milk, which retained the exact shape of the parts when it 
was removed. 

The complaint which I have described as aflfecting these 
two infants, though closely allied to laryngismus stridulus, or 
crowing disease, is obviously very distinct in its nature, or more 
truly perhaps in the amount of nervous matter involved in the 
morbid action. Possibly the same difierence may exist between 
them, as between apoplexy and local convulsion, or, as Dr. Ley 
suggests, palsy. Whatever it may be, the distinction between 
them is very marked. In laryngismus there is no insensibility, 
no crowing, except immediately on recovering from the fits 
of breathlessness, no apparent illness whatsoever in the inter- 
vals, no pallor or coldness of the surface, or feebleness of the 
action of the heart, or of the pulse at the wrist. In the aflFec- 
tions which I have just described, on the other hand, there was, 
from the moment of seizure, an utter imconsciousness and insen- 
sibility both in the fit and inteiTal, so much so indeed that even 
a cry did not escape either of the infants, except in one instance, 
when the first was plunged into a hot bath ; there was an incapa- 
bility of swallowing, excessive feebleness of the heart's ac- 
tion^ and coldness of the surface of the body. In the second 



Dr. Griffin's Medical Problems. 37 1 

child, there was at one time, when the crowing subsided during 
a longer interval than usual, some approadi to stertor in the 
breathing. I ought perhaps to notice one other distinction be- 
tween this and the crowing disease of Dr. Clarke and others, 
that it did not terminate in general convulsions as the latter 
usually does. 

It is exceedingly difficult even to speculate with any proba- 
bility on the cause of this remarkable affection, or to connect it 
with any certain pathological condition. From its occurrence 
a few days after birth, at which period, (Billard states, general 
ramollissemerU of the nervous centres is most common, I should 
have been disposed to connect the symptoms with some such dis- 
organization, if, in the second case, the brain had not been 
found apparently healthy ; and I should have attributed them 
to some congenital defect, which the weak appearance of the 
other infant might in some degree countenance, only that no 
suspicion of the kind could be entertained in reference to the 
second. It was bom a strong, plump, round-limbed little fel- 
low, in every way as promising for long life as one could desire. 
It might, indeed, be said that the very earliest evacuations were 
unhealthy, and the sudden screams out of sleep, described by 
the mother, indicated something wrong from the commence- 
ment ; but these symptoms are of every day occurrence with 
other infants who go on well notwithstanding. 

From a fair consideration of both cases it becomes a ques- 
tion of great interest, whether the complaint might not be one of 
mere functional derangement, as we are well assured many 
cases of fatal convulsions are. It was in both instances preceded 
by disorder of the bowels, and on the evening previous to the at^ 
tack by diarrhoea. Supposing it to be a functional affection, to 
what cause are we to attribute it ? An experienced practitioner 
informed me he had met with similar cases which also proved 
fatal, and that he believed them to depend upon retention of the 
meconium. In the first case narrated, however, castor oil was 
^iven to the infant immediately after birth in the usual manner, 
and repeated as occasion seemed to require ; and in the second. 



372 Dr. GriflBn's Medical Problems. 

calomel and castor oil were given until the evacuations assumed 
a natural appearance. Could the hard plug of coagulated roilk, 
found in the cardiac orifice of the stomach of this child, by pos- 
sibility produce such a frightful affection of the nervous centres? 
I now proceed to the cases in which the question at issue be- 
tween a portion of the profession and the late Doctor Ley is 
more directly involved. They accurately agree with those al- 
ready published by that gentleman and others, and are given in 
detail only because the amount of those already upon record is 
far too slight to admit of safe general inferences as to their patho- 
logy or treatment. In all diseases, the treatment of which is 
difficult or obscure, the numerical system of deduction so suc- 
cessfully adojpted by Louis in affections of the lungs, is the only 
one wortii our attention, and without a large number of cases 
this cannot be resorted to, even in the imperfect manner, which 
these, \i^hen given loosely by different individuals, may admit 
of. 

A fine, stout, muscular little fellow, at the age of seven months, 
was seized, in the nurse's arms, with sudden suspension of the 
breath, but after a slight struggle, and gasping attempts at 
inspiration, accompanied by a crowing sound, he in a few mo- 
ments recovered. As the fits recurred two or three times in 
the course of the day, and occasioned a very just alarm to the 
parents, I was requested to see the child, whom I found playful 
and smiling on the nurse's knee before me. From the descrip- 
tion of the fit, as it was called, I had no doubt as to its nature. 
My acquaintance with it having been chiefly derived from Dr. 
Clarke's communications on the subject, I entertained his views 
of its cerebral origin, believing that in this case the brain had 
become affected from the irritation of teething in a naturally 
plethoric habit. The gums were therefore lanced, active pur- 
gatives were given ; and the child, who was a great feeder, was 
restricted to a lighter diet. The complaint recurred slightly for 
some days, when one or two teeth appearing, it ceased altoge- 
ther, and for five or six weeks the child continued perfectly well. 



J 



Dr. Griffin's Medical Problem. 373 

It was then, however, attacked with a more yiolent fit than be- 
fore. As well as I can recollect (for I kept no notes of the 
case) I then lanced the gums again, blistered behind the ears, and 
directed some purgatives. The complaint recurred frequently 
when the little fellow laughed or cried, and sometimes he 
awoke out of sleep with the gasping and crowing. He passed 
some days entirely without an attack ; on others he had one or 
two. I now directed assafoetida and antispasmodics for him ; but 
as there was no satisfactory amendment, the fits still returning 
occasionally in a very alarming manner, a consultation was pro- 
posed with a physician of eminence and experience. Tiiis gen- 
tleman took altogether a different view from mine of the disor- 
der, and I saw evidently that he had either never seen it, or 
never distinguished it as a specific aflTection. He spoke of the 
crowing as singultus, and attributing it to acidity of stomach, 
with derangement of bowels, recommended that milk and its 
other usual diet should be laid aside, and broth substituted ; a 
carminative mixture with rhubarb and magnesia was also di- 
rected. There was, however, no improvement, and on the second 
day after the child fell into convulsions. Tiie face was very 
much distorted, and the convulsions were confined to one side, 
the other appearing to be palsied. Three leeches were applied 
to the temples, and the child was put into a warm bath. After 
a second consultation four leeches more were applied, and the 
little patient at length recovered, but was hemiplegic. The pa- 
ralytic affection, however, disappeared, after the application of a 
blister to the nape of the neck and vertex. The improvement, 
though wonderful, was however temporary ; the fits of crowing 
returned on the next day, and in two or three days, the little 
sufferer fell into convulsions again, accompanied with profound 
coma, from which he never recovered. 

The mother had another child in the following year, which 
fell into convulsions in, I believe, the second month, and died. 
I did not see it, but mention the circumstance to show the fa- 
mily predisposition to such affections. 



374 Dr. Griffin's Medical Problem. 

Some months afler my attendance on the foregoing case, J 
was sent for by a lady who had lost many children, to prescribe 
for an infant that had been just seized with convulsions. She 
had only this little one, of seven or eight months old, and ano* 
ther, a weak, emaciated boy, aged four or five years, who was suf- 
fering with paralysis of the lower limbs from spinal disease, oat 
of a family of eight children, most of whom had died of convul- 
sions or hydrocephalus. The child was in a warm bath, and re- 
covered from the fit when I had arrived. It was like the for- 
mer, of a gross habit, and though still at the breast fed largely. 
It took bread and milk often, was allowed broths, and sucked 
meat greedily. It certainly did credit to the diet, for it was 
one of the finest children I ever saw, large, round, plump, and 
rosy faced, with eyes full of light and intelligence, and a dispo- 
sition full of play. I found it had been attacked in a similar 
way about three weeks or a month before, and that a scabby 
eruption, with which the whole head and upper part of the face 
had been covered, was then first observed to decline. It had 
been teething for some time, and used to dribble a great 
deal, but this drain of saliva had also lately diminished. The 
convulsions, as described to me, were general. As the child was 
very plethoric, three leeches were applied to the head, the 
gums were lanced, he was freely purged, and small blisters were 
applied behind the ears. On the following day, although there 
was no return of the convulsions, he had once or twice, as the 
attendants described, a slight fit, though without spasms of the 
limbs. A more minute inquiry convinced me that it was an at- 
tack of the crowing disease. The child, they said, stiflTened, 
and lost its breath ; and although the crowing did not strike 
them particularly, when I imitated the sound and gaspmg man- 
ner of the infant, they at once recognized the perfect resem- 
blance. I believe, indeed, one reason for the apparent infre- 
quency of this disease is, that it is always spoken of as a convulsive 
fit by the nurse or attendants, and as the phyucian is seldom in 
time to witness the paroxysm, unless he institutas an accurate in- 



Dr. Griffin's Medical Protdem9. 375 

quiry, and obteins a faithtlil and minute description of tiie aU 
lack, be necessarily oonfoandis it with the common convulstond 
of infants. I was^ indeed, for several dirys in attendance on this 
little boy, during which he had several returns cf the fit, before 
I had an opportunity of verirying tny conclusions, although frdm 
the mother's faithful picture of the fit, efler her attention 
was directed to the importance of discrimination, I was per*^ 
jectly convinced on the subject. The blisters were now kept 
open with aavine ointment ; the bowels, which were exceetdingly 
costive and obstinate, were regularly opened ; and he was re- 
stricted to liquid and &rinaoeous diet. In less than a week lie 
seemed perfectly well. 

On calling to see the ehild in about a fortnight af\er, I (bund 
him mudi puUed down ; his face pale, lus look dull and de* 
pressed, and be had lost his clieerftilness ; there had been, 
however, no return of the crowing. Somewhat apprehensive of 
the eflRects of the debilfty which had followed the regular 
purging and restricted diet, I again aHowed Uie little felk>w 
broth, with some bread or panada ; in a few <iays he began to 
look up again, and before a week his former bri^t looks and 
playfulness bad returned. Aboirt two months after tbit I was 
once more summoned to see hitn, and to my great regret found 
this fine boy had relapsed into a worse condition than be had 
been in any former attack ; the gasping and breatblessness re« 
curred frequently, and were very protracted ; and the recovery 
of the breath, with the loud crowing, took place only after 
roo$t distressing struggles. He was still teething, bi* bowels 
were very confined, and I lamented to see that the eruption on 
the head and face had nearly diaappeared. The same treat-^ 
ment as before was once more resorted to; lanoing the gums} 
the warm bath ; repeated doses of active purgatives, and ene^ 
mata; leeches were also again applied — these last remedies 
chiefly in consequence of the very plethoric habit of the child* 
When a sufiicient degree of depletion had taken place, the fits 
atiU recurring at intervals of two or three bours, or oftener, blia* 

VOL. XII. NO. 36. 3 c 



376 Dr. GrifBn's Medical Problems. 

ters were applied behind the ears^ and injections with assafoetida 
were administered. On the next day a blister was applied to 
thenape^and a few drops of laudanum were added to each ene* 
ma. Other antispasmodics were also administered by the 
mouth, but without evincing any influence in arresting the 
frequent attacks of the complaint. The laudanum was given 
two or three limes in the injections, and did not produce any 
effect whatsoever, upon which I did not push it further. The 
little patient passed on the whole a better night than the pre- 
vious one ; but on the succeeding day sufiered much, the attack 
occurring from the merest trifle, and attended with more ap* 
pearance of convulsion. Towards noon he appeared stupid 
and heavy, and the pupils more dilated and sluggish in their 
movements. As the pulse was quick and feeble, the face pale, 
and the skin cold, I now gave some wine, and fed the little 
fellow occasionally with broth. An astonishing improvement 
followed the use of the wine, such, indeed, as I have not unfrco 
quently witnessed in the advanced stage of hydrocephalus, where 
the great debility seemed to demand it, but invariably without 
leading to any permanent good. The insensibility and dispo* 
sition to fall into a state of coma completely disappeared, the 
little sufferer looked up again with evident consciousness, and 
the fits of suspended respiration were shorter and less dis* 
tressing. In two or three hours after, however, when I repeated 
my visit, I found all matters worse ; the respiration was loud, 
and tracheal, and he seemed again insensible, though still reco* 
vering some degree of cousciousDess whenever the difficulty of 
breathing occurred. In this utterly hopeless state I was obliged 
to leave him to visit another patient who was in imminent dan* 
ger, and learned afterwards that he died towards morning, con* 
vulsed. 

The only symptom of convulsion which I witnessed through- 
out was the contraction of the thumbs in the palms of the 
bands. The first attack, the one with which the child suf- 
fered a fortnight or three weeks before I was called to see h;m. 



1 1 . Griffin's Medical Problems: 377 

and that on the day I commenced my attendance^ which^ how- 
ever^ I was not in time to witness, were both, I believe, in- 
stances of common convulsion. I had not read Dr. Ley's pa- 
pers on this disease until a day or two previous to the boy's 
death, when I was induced to examine the state of the lym- 
phatic glands particularly. I found the glanduke concatenateB 
erdatged all doum the neck, but did not obtain permission for 
a post mortem examination. 

A third case happened in the practice of my brother, who 
has given me the following account of it. "In the year 1835 
M. W., a diild a year old, began to be affected with derange- 
ment of bowels, white tongue, loss of appetite, and diarrhoea, 
attended with thin, gruel-like discharges of a pale colour ; these 
attacks, which were at first attributed to difficult dentition, were 
usually got over in a week or ten days, but their repeated oc- 
currence produced a degree of delicacy of look, and softness of 
fibre, and very much checked her growth. In the autumn of 
that year, being at the sea side, she got so severe an attack of 
diarrhoea, that for a day or two her life was despaired of ; she 
came home in a very delicate state, with pallid look, white 
tongue, pale-coloured alvine discharges, which were now, how- 
ever, of a healthy consistence, and she had lost her relish 
for all food except milk and thin gruel. In this state she 
was attacked with nervous startings, and occasionally also with 
what the mother called * croupy breathing,' (laryngismus 
stridulus of Dr. Ley ;) this last symptom was never so violent 
as to suspend the breathing entirely, or cause much distress. 
It was in other respects the loud sonorous inspiration so 
well described by Dr. Ley, always sudden in its onset, and 
passing oflT entirely in a minute or two. This state of things 
lasted some time, and during the continuance of it she was at- 
tacked with convulsions, which came on frequently during a 
day and a night, and which, after she had been blistered and 
purged, were at length subdued by an enema with fifteen drops 
of laudanum repeated once or twice. As the nervous startings; 



378 Dr. Griffin's Medical Probtemi. 

the ^ croupy breathing/ and the conTiilsiooSj were all con- 
sidered connected with that irritable and over-sensitive staW 
of the nerves which is often conjoined with debilityt ^^ ^^^ 
casional use of a sedative with tonics was recommended, and (a 
tonio mixture, with some tinct. opii, having beea found to dis- 
agree, by interfering widi the effect of the necessary openiag 
medicine) the sedative was usually administered in the foma d 
an enema, with fifteen drops of laudanum, whenever the slartkiga 
or ' crpupy breathing* shewed themselves. Under this plan, and 
by attention to the bowels, she passed six months without any 
return of the convulsions, and was rarely a^ctod with the starl- 
ing and * croupy breathing,' iniiich were always watched, and 
when they did occur subdued by the enema with tinct opii. — 
She had a very capricious appetite all this time, the tongue 
usually coated or white, and for a considerable period she fTouId 
take nothing but bread soaked in wine, on which regimen she 
gradually, however, gained somefi^sh and strength. I called at 
the house one morning, her bowels had been rather confined for 
some days before ; she had a fit of the ' croupy breathing' in my 
presence, which was not a very violent one* When it w^ over, 
and the child was quiet again, the mother was expressii^ her 
apprehensions that this was premonitory of a convulsive attack, 
and asked me if I thought so. I gave an answer teading to 
quiet her fears, but had scarcely done speakiag when the child 
had a violent convulsive fit, which came on without any of 
the ^ croupy breathing/ and lasted nearly a minute. I pat a 
blister on the nape of the neck, ordered some opeaii^ laedicine 
immediately, and remained i|i the house three hours, daring 
which time she had no r^um either of ' croupy breatWi^ or 
convulsion. I was obliged togo eigbjkeea or twenty miles off that 
day, and on my return on the next, at noon, foMild the Anily 
in the utmost distress, the convulsions had returned repeatedly 
during the night, though the bowels had been well moved^ and 
the blister bad ris^n. The fits were growing more violent and 
very frequent^ returning every half hour or^twenty minutes. I 



Dr. Grlfiiii's Medkat Problems: 379 

applied three leeches to the temples^ gave the laudanum enema^ 
s^A applied the stimulating dressing to the blister; the enema 
was repeated at intervals of about wai hour^ being usually given 
wltenever a fit ocGUrred of more than ordinary violence. After 
it was given five or six times it had an evident effect on the 
paroxysms, which thou^ not lessened in frequency were very 
much dimii^isfaed in violence, and indeed were now very slight. 
The child at this titne had a very exhausted appearance, her 
face was pale, her pulse rapid, and there was so much insefisi- 
bility that Ae coudd scarcely be got to swallow tlie drink which 
was occasionally put between bar tif>8 with a spoom The 
insensibility was perhaps due to the opiate enemala, but as the 
convulsive paroxysms still returned, though not so violently, 
and the comatose state was one to which the case naturally 
tended, though no opiate Iiad been given, I feared if it was 
allowed to continue, and my inference proved correct, the 
time lost would be irretrievable. The child was already blis- 
tered, and as new blisters would be too slow of acting, the 
only remaining alternative I had was to make an opeinng aloag 
tfie sagital suture, down to the bone, and place a doasil of lint 
in it, wet with sjtfrits of turpentine; she diowed some seasiUlity 
to this by movements of the head from side to side ; there was 
some little tendency to Ihe fits for two or three hours after- 
wards, but they were so sb'ght as scarcely to attract notice. 
The insensibility wore gradually off, and. by the Bext eveniag 
she was able to take some milk and gruel, and recovered from 
all the eflects of the attack, exeept the debility. 

<^ The child lived eight months after this Mack, but ms an 
Extremely delicate conditioQ ; her growth was checked ; she 
showed a disposition to rickets in die limbs; aequifed a douUe 
lateral curvature of the ^>ine, and though nearly three years of 
age eould neither speak nor waUu During this interval she had 
occasionally, but very rarely, returns of the ' eroupy bsealhing' in 
a slight degree, and sometimes returns of the nervous startiogs, 
which symptrais were always attended Iv and subdu^ i» the 



380 Dr. Griffin's Medical Problems. 

usual manner when they did occur. Ijcould^ever perceive in 
this child any appearance of swelled glands in any part of tlie 
neck during her illness, nor any where else except beneath tlie 
occiput, where some small ones could sometimes be felt^ pro- 
duced, probably by the discharge from the head, which was 
kept up to the time of her death. This event occurred after 
an attack of diarrhoea and vomiting, much slighter in degree 
than many that she had had previously. There was no exami- 
nation of the body.** 

As the intimate pathology of these cases is likely I fear for 
a length of time to remain a mystery, it becomes a matter of 
extreme importance to ascertain in how far the pathology of 
the nerves in general and the inferences deduced from analogy 
may determine the general question whether they belong to the 
class of paralytic afiections, and are dependent on the pressure 
of the recurrent nerves by lymphatic glands ; or the convulsjve 
disorders, and arise from some change occurring at the origin of 
the par vagum, aflecting chiefly the superior laryngeal branches. 
The late Dr. Hugh Ley has already in a very elaboMe work 
considered this subject in all its relations. He has indeed 
brought such a mass of information together in support of his 
views, and reasoned so ingeniously, that he has I believe made 
converts of a great body of the profession to his opinions, and 
leil few disposed to question their correctness as regards some 
instances of the disease. There are, after all, difficulties which 
Dr. Ley has by no means satisfactorily got over, and which to 
my mind are sufficient to throw doubts on his whole hypothesis. 
I am not indeed, with my very limited experience of such cases, 
assuming to restore the opposite and formerly popular belief 
upon the subject, or to set the question at rest, anxious only to 
keep it still open to inquiry, and prevent the present practical 
influence of conjectures, which are problematical if not errone- 
ous. Doubtful, however, as I am of the correctness of Dr. Ley's 
opinion, at least as it applies to the vast majority of cases, I 
cannot in common with the profession at large be insensible to 



Dr. Griffin^s Medical Problem. 381 

the advantages which must result to medical science from the 
philosophical and perfect mann^r in which he has brought the 
point at issue between him and former practitioners before the 
puUicy and the candour with which he has discussed IL It 
would indeed be a great gratification to me, as well as a help to 
our arrival at the true and just pathology of laryngismus 
stridulus, if a physician who devoted his mind to the inquiry 
more closely than any one before him, were still living to 
consider the few observations which I may here venture to 

offer. 

The physiology of the parts engaged in the disease, and 
many facts illustrative of the general pathology of the nerves, 
give an extraordinary speciousness to Dr. Ley's views, whi.ch 
we shall not find so fully supported on a more minute examina« 
tion. I shall, however, first consider what value should be at< 
tached to one or two symptoms, the presence of which, in the 
majority of cases, seems undeniable, and with respect to one at 
least is, in Dr. Ley's opinion, necessary as the exciting cause of 
the malady ; I mean eruptions on the scalp, ears, or face, and 
enlargement of the lymphatic glands in the neck or thorax. 
When we reflect how rarely the most alarming symptoms of the 
disorder, the suspension of respiration and crowing, are found 
in connexion with disease of the head, which is so common ; hqw 
impossible it is to account for that infrequency on any supposi- 
tion of the aflbction originating in disease either of the superior 
laryngeal nerve, or of the origin of the par vagum ; and how 
perfectly it seems to be explained on the opposite view, as 
arising from pressure on the recurrent branches by enlarged 
lymphatic glands — when further we H^ d that most cases are 
attended by eruptions about the scalp, ears, or face, with 
' enlarged glands just in the course of the recurrents ; when we 
know that injurious pressure may possibly occur, the effect of 
which must be diminished power in the nerve ; i^nd lastly when 
we are aware that the consequences of such defective power 
or paralysis must be diflScult if not impossible respiration, we 



382 Dr. GriflUn's M*dkal Problems. 

must admit that a very specious case is made out in faram of 
the only hypothesis whidi oflers a solution of the di6Sciiltie8 
involved in the pathology of laryngismus strrduhis. It is, how- 
ever, worth while to examine the separate links of this imporing 
chain of reasoning. 

It must strike every observer with regard to the enlarged 
glands, that asrihey are very common in children, as common 
almost as the disposition lo struma, the crowing disease should 
be common also. Dr. Ley anticipates this objection, but he puts 
it only as applying to the immunity of adults from such an 
affection, which he accounts for .T)y saying : 1st, adults are 
comparatively free from the causes which produce such en- 
largements ; 2ndly, where the tracliea has acquired the aduH 
si^e, it gives more protection to the recurrent ; and 3rdly, t!ie 
larynx and glottis of the adult are much larger than those of the 
{nftint These ar^ments, strong as they are in explaining why 
sadi an afiection should rarely occur in an adult, by no means 
sati^ us as to his perfect immunity : amidst aH the tumours to 
which adults are subject about the neck, it is rational, if Dr. 
Ley's hypothesis be true, to demand the citation of at least one 
fair case of laryngismus stridulus arising like it, resembling It, 
and terminating as it does in the infant. Hie real difficulty, 
liowever, is not about adults but about grown children, between 
whom cmd mere infants there can exist no extraordinary dispro- 
portion in the si^e t)f the trachea, larynx, or glottis ; and in 
whom the di^osition to enlargement of the lymphatic glands 
is, I should say, rather greater. Why are rtot grown children 
attacked with laryngismus stridulus ? I have never seen the 
complaint except in mere infants; all Mr. Robertson's and 
most of Dr. Ley's cases appear to have been under two years 
of age ; and Dr. Underwood speaks of it under the head rf 
inward fits, as one of the disorders of early infkncy. 

The mere presence of enlarged glands in this complaint, 
'may certainly, as Mr. Robertson of Mandiester suggests, be a 
coincidence only. Dn Marsh asserts that he has* never seen 



Dr. GriflBn's Medical Problems. 383 

the crowing disease in any but infants of strumous habits, and 
with such^. enlarged glands are usual^ whedier they suffer from 
any such affection or not. Strumous ophthalmy is very fre- 
quently attended by enlarged glands, and disappears as the 
enlargement subsides, yet it furnishes no argument of the de- 
pendance of the one on the other^ both being the result of a com- 
mon taint in the system. Enlarged glands are indeed, apt to 
appear with most strumous diseases of infants. Mr. Swan 
states that he has frequently found the glands within the chest 
enlarged in children who died of hydrocephalus, yet I question 
whether there was any such phenomenon as crowing in a single 
one of these cases. 

Mr. Robertson very fairly inquires, '< is it probable, that in 
a soft yielding structure like the throat, absorbent glands should, 
by pressure on the par vagum and recurrent nerves, cause a di- 
minution or extinction of nervous energy T' If the pressure 
could be supposed sufficient, no one could doubt the effect : tlie 
question for consideration is, can it be so ? The only satisfac- 
tory instances of such effects from such pressure, adduced by Dr. 
Ley, are those cited fix)m Sir Charles Bell's work, in which 
partial paralysis of the face occurred from the pressure of an 
enlarged gland on the seventh nerve between the mastoid pro- 
cess and angle of the jaw. Even in these^ however^ the analogy 
is not perfect, as one may readily conceive, that an equal degree 
of pressure would occasion far more important effects in that 
situation, .than in the lower and less resisting parts of the throat. 
If the pressure of enlarged glands could in the latter situations so 
readily affect the energy of the nerves^ it is wholly inconceivable 
tliat it should not more frequently happen in strumous children 
with enlarged glands ; and admitting for a moment, the assump- 
tion that the effects of the pressure Would be immediate, it 
seems extraordinary that it should not often take place in 
those violent strainings or twistings of the neck, which in 
their games and exercises so continually occur. This last ob- 
servation, I have made, because Dr. Ley states, in explaining the 
VOL. XII. NO. 36. 3 o 



384 Dr. Griffin's Medical Problems. 

occasional absence of the crowing, '^ that glands not instantly 
in contact with a nerve niay, during the varied contractions of 
the muscles of the neck in crying, coughing, laughing, or sudden 
twisting, produce at once contact and compression, when tem^ 
parary asphyxia wiU be the resultJ'* I do not> however, be* 
lieve, that momentary pressure on a nerve, however greats 
occasions any inconvenience at all, of which we hav6 every day 
evidence in our own persons. To impair the energy of a nerve» 
the pressure must be continued for some time, and when once 
impaired, it is a considerable time before it is again recovered, 
although the pressure be removed. 

This brings us to the consideration of the paroxyMual nature 
of the disease, which Dr. Ley acknowledges be has always look- 
ed upon as the strongest argument for its spasmodic character. 
Adopting Mr, Swan's explanation of the paroxynnal nature of 
all convulsive and painful disorders of nerves, quoted by Dr. 
Ley, " a nerve cannot at 6rst bear a diseased action without 
rest, any more than a healdiy one, and therefore the diseased 
action after a certain period, ceases to make any impression; 
but atler this rest, the nerve acquires fresh powers, and is again 
fitted for the same action. In palsy, on the other hand, the 
pressure being permanent, the loss of sense or motion, or of 
both, is permanent also." If this were universally true, it 
would be altogether fatal to Dr. Ley's supposition of the para- 
lytic nature of laryngismus stridulus, as he would find it im- 
possible to reconcile the rapid recovery, easy respiration, and 
long intervals of perfect relief between fits occurring on the 
same day, with permanent defect of power. But it is only 
true, he says, as far as the nerves of sensation and volition are 
concerned ; for in paralytic ailments of the muscles supplied by 
respiratQry nerves, the palsy, though continuous, is not con- 
stantly manifest ; and in proof of this, he instances the eflfect of 
pressure on the portio dura, the defective power occasioned by 
which is not observed, till in speaking or in emotion, or diffi- 
culty of respiration, vigorous action of the muscles is required. 



Dr. GriflSn's Medical Problems. 385 

So in like maimer he says^ in the glottis '' the eflTects of the 
enfi^bled^ if not paralyzed, state of its opening muscles, are 
only observable in those more vigorous efforts which are made 
when the respiration is hurried or Impeded, as in fright, fits of 
anger, sudden awaking from sleep, in consequence of some 
external impression, and in screaming, crying, coughing &c." 
It appears to me, that the whole question of the spasmodic 
or paralytic nature of the disease turns chiefly upon the cor- 
rectness of this distinction which Dr. Ley has drawn between 
the voluntary and respiratory nerves. To take the instance 
which he has himself put forward in illustration, that of the 
seventh nerve, he has certainly fallen into error, probably in con- 
sequence of having seen no case in which it was perfectly pal- 
sied. In perfect or even in very considerable palsy of the por- 
tio dura, I have always seen the face permanently dragged to 
one side, whether the muscles were in active contraction or not. 
In slighter cases, where the energy of the nerve is not much im- 
paired, I am aware the defective power is not observable until 
the opposing muscles are thrown into vigorous action, but this 
would be equally true, if the opposing muscles were si^>plied 
by purely voluntary nerves. The law that if the pressure is 
permanent, the defectof po«irer must be permanent exactly in the 
same degree, k in fact true of the portio dura, as it is of all other 
nerves ; and referring this law to the glottis in paralysis of the 
recurrents from pressure, whatever effect is produced, and in 
whatever degree, must be as permanent as the pressure,, that 
occasioned it. I do not here, take into account the greater de- 
fect of power observable in the palsied muscles of one side of 
the face, when the- opposing ones are in vigorous action, or 
by those of the eydid when we attempt to close it, or in the 
glottis when the closing muscles are spasmodically or energe- 
tically contracted. In these instances the effect arises from 
active contraction of the healthy muscles, not solely from the 
palsy of the others, and therefore can last only as lodg as mus- 
cular action usually lasts — ^a few moments. But even this effect, 

i 



386 Dr. Griffin's Medical Problems. 

in its constant recurrence^ if not in its continuousness^ bears a 
permanent relation to the paralytic affection, since no action of 
the unaffected muscles can take place without its appearing. 
It is clear, therefore, that if we are to explain the paroxysmal 
nature of the crowing disease, by any such efiects of loss of 
power in the recurrent nerves, we must assume that when once 
the paralysis is more or less imperfectly established, whatever 
ill result or difficulty of breadiing is at any time observable 
in laughing, crying, screaming, fright, &c, should invariably 
return with every recurrence of these, and a certain amount of 
mischief, however slight, should be always distinguishable when 
at perfect rest ; just as the slightest defect of power in the 
portio dura is observable in the slightly parted eyelid while the 
patient sleeps. But the &ct seems entirely otherwise ; children 
affected with this disease pass days without the slightest appear- 
ance of illness, between two fits of suspended or difficult respira- 
tion, during which they laugh and cry, and are excited as 
usual. 

The foregoing observations must sufficiently dbplay the 
error Dr. Ley has fallen into with regard to the effects of palsy 
of the recurrent nerves in occasioning the phenomena of laryn- 
gismus stridulus. On the whole, after all the consideration I 
have devoted to the complaint, and having, I think, given 
other ingenious arguments of Dr. Ley their full weight, I feel 
still disposed to continue a disciple of the older doctrine, and 
to hold the affection as one of spasm or partial convulsion like 
cramp, rather than of paralysis. The fact of its being fre- 
quently benefited by antispasmodics, with which Dr. Under- 
wood tells us he latterly cured most cases, and by anodynes, as 
opium, hemlock, cicuta, &c., recommended by all modem 
writers on the disease, favours this view ; the circumstance of 
the sudden occurrence of the gasping and crowing on washing 
with cold water, laughing, crying, or agitation of mind, also 
supports it as well as the almost universal coexistence of the 
carpo-pedal contractions, and the frequent termination of the 



Dr. Griffin's Medical Problems. 387 

complaint In convulsions. But above all tliese, as a strong 
analogical evidence for its spasmodic character^ I place its 
paroxysmal nature, and the manner in whrcb the paroxysms 
occui*. The office of the superior laryngeal nerves would lead 
us to expect a disposition to spasmodic action on the least 
irritation or excitement, recurring at irregular intervals, depen- 
dent of course on the return of the irritation or excitement, but 
far more on the increase or decrease of the susceptibility of the 
parts, and disposition to spasmodic action. Dr. Mayo very 
justly remarks, that '^ a frequent disorder in parts endowed 
with acute sensibility, like the mucous surface of the larynx or 
eyelids, is an increased susceptibility of the sentient surface, 
and a tendency to spasmodic action in the adjacent muscles, 
which usually act from impressions received upon it. Thus in 
the urethra a morbidly sensible state of a part of the mucous 
membrane produces spasmodic stricture, or a continued con- 
traction of the surrounding fibres of the accelerator urinae. In 
like manner is produced spasm of the glottis, in cases of ulcer 
within the larynx and in hydrophobia." The muscles supplied 
by the superior laryngeal nerves are the sentinels of the chink 
of the glottis, as the orbicularis is of tlie chink or opening of 
the eyelids, and their action is directed by an exquisite sensibi- 
lity of the parts, which is at once manifested on the attempted 
entrance of anything injurious to the lungs, whether it be a 
drop of water, or a volume of mephitic gas. One can well 
understand how dangerous any morbid increase of the sensibi- 
lity of such nerves at their extremities, or any existence of 
irritation at their origin, might prove, why the danger should 
occur in irregular paroxysms, and why the exciting cause whiclv 
occasioned them on one day should be altogether powerless on 
the next. If it be inquired further, why such a dangerous 
result as the suspension of respiration in the crowing disease 
" does not then occur more frequently, it can only be replied, 
that we are wholly ignorant of the morbid condition which 
disorders the functions of those nerves ; or whether it exists at 



388 Dr. Griffin's Medical Problems. 

their extremities^ or their origin in the medulla oblongata^ and 
can therefore offer no reply. If the affection be organic, we 
should find it more difficult to account for the occasional reco- 
veries under very mild treatment, than the usual fatality under 
the most active. If it be functional, and therefore symptomatic, 
we can better understand why it might depend on a variety of 
causes, at one time upon an affection of the head, at another of the 
bowels, at another upon dentition ; we can comprehend, too^ how 
these several aflfections, influencing peculiar predispositions, may 
in one child occasion hydrocephalus, in another convulsions, in 
a fourth, that more rare infantile disorder, the crowing disease. 
Of the treatment of laryngismus stridulus I have but little 
to offer. In this view of it, which is the one adopted by Dr. 
Marsh, the obvious preliminary to a judicious plan of cure is 
to ascertain, by a careful examination of all the functions of the 
body, whether there be anything wrong to which we could 
refer the origin of the disease. When any such causes or 
complications, whether in the head or abdomen, are found to 
exist, their removal should form our first object, but always 
with reference to the strength or tone of the system, which in 
an affection invariably found in connexion with a strumous 
habit, cannot be lowered much without injury. The mainte- 
nance of the general health and strength seems to be on all oc- 
casions a matter of importance, but still more so in those cases 
in which no complication exists, and where probably the com- 
plaint very much depends on debility, in connexion with either 
a cachetic state of the body and wasting, or preternatural irri- 
tability with plethora. From my experience of the complaint 
I am disposed to believe that no treatment, directed entirely 
with reference to its complications, or on the supposition of 
its being a pure cerebral affection, can be successful, and I 
fully agree with those practitioners whose great anxiety is to 
restore the natural tone and firmness of the system, giving tonics 
where there is deficiency of power, and antispasmodics and ano- 
dynes where there is great irritability. To attain our object. 



Dr. Griffin's JUedkal Problems. 389 

however^ it must always be held in mind that in the chronic 
affections of children, the exhibition of medicines is secondary 
to the management of diet and change of air. The former 
should be regulated with the utmost care, and in many cases 
Dr. Marsh's suggestion with respect to a succession of good 
nurses during the whole period of dentition might be attended 
with advantage. Change of air not only in this complaint but 
in all obscure chronic cases is invaluable, being in fact the 
only remedial measure about the beneficial influence of which 
there can be no question, however our views of the nature 
or pathology of the disease may alter from time to time. I 
have often thought that in such complaints, and still more in 
those which are supposed to be endemic, it would be most de- 
sirable, in every instance where it was at all practicable* to treat 
the patient in an atmosphere differing as much as possible from 
that in which his disease originated. I believe many cases of 
croup and cholera, such at least as are not of the rapid type, 
might be treated successfully if removed into a new atmosphere, 
which are utterly hopeless when the cure is attempted in the 
locality where the patients sickened. Whether a child affected 
with laryngismus have change of air or not, however, it is es- 
sential that he shall sleep in a cool and airy apartment, and that 
when the weather permits he shall be as much as possible in 
the open air. There is no one point in which children are 
more mismanaged than in the arrangement of their sleeping 
apartments, which are commonly the most close and confined in 
the whole house. 

Dr. Merriman has recommended the use of continued pur- 
gatives, so as to procure at least two free motions daily. When 
the child is plethoric, or is otherwise likely to bear evacuations 
well, it would, I have no doubt, be an advisable plan ; indeed 
in young children the bowels are usually moved as often as this 
in the twenty-four hours with advantage, but the recommenda- 
tion, in any case, should be followed with constant regard to 
the strength of the little patient, and the apparent effect. He 



390 Dr. GriflRn's Medical Problems. 

has also advised the use of soda or burned sponge^ probably with 
the same view which induced Dr. Ley to propose the prepora* 
tions of iodine, to diminish the size of the enlarged glands in the 
neck and chest, to the pressure of some of which on the recurreot 
nerves he attributed the disease. Doubtful as I am of the cor- 
rectness of this opinion, I should think it judicious to adopt the 
treatment, especially as it could in no sense interfere vrith other 
remedial measures on which I should perhaps set more value. 
It seems to be a fair indication to endeavour as much as possi- 
ble to counteract or overcome the general strumous disposition 
in those affections, which are seldom or never found to occar 
except in conjunction with it. 

I have offered these few unsatisfactory observations without 
wishing to attach more importance to them than they merit. I 
believe both the pathology and treatment of the disease are 
still very uncertain, and that it will require all the considera- 
tion and inquiry which observant practitioners can bestow upon 
the subject for many future years to attain a just knowledge of 
either. The following summary of the amount of our present 
information and of the facts connected with the disease, may be 
useful to subsequent inquirers. 

By the concurrent testimony of almost all who have noticed 
the affection, it occurs for the most part, if iiot wholly, in stru- 
mous habits. 

It is frequently found in connexion with enlarged glands in 
the neck, and perhaps in the thorax. 

It is frequently found in connexion with eruptions on the 
face, ears, or scalp. 

It frequently terminates in convulsions, and is sometimes, 
though very rarely, ushered in by them* I believe it may be 
said that nearly half the fatal cases on record terminated in 
convulsions. 

It is met with in families in which children are subject to 
head affections or convulsions, but who have also the strumous 
disposition. 



Dr. Nagle on Obstetric Auscultation. 401 

It ifl sometimes met with in connexion with an apoplectic 
or comatose state from the commencment, as in the cases of 
crowing apoplexy which I have described. 

In a great proportion of the cases which terminated fatally 
there was not the least symptom of head affection through their 
whole course, if we do not look upon theoccasional fitsof breath- 
lessness and crowing as indicative of it, and the children were 
as well apparently, a fdw moments before death, as they were 
previous to the first attack of the disease, or as any children 
could be. 

The complaint is sometimes, but rarely, attended by cough 
and permanent difficulty of respiration. 

Perhaps it may be said that from one-third to half of all the 
cases of which we have any account, terminated in death.. 



Art. XXII. — Observations on the Use of the Stethoscope in the 
Practice of Midwifery. By David C. Nagle, A. B., 
M. B., one of the Physicians to the Dublin General Dis« 
pensary. 

Obstetric auscultation having scarcely as yet advanced beyond 
its infancy, it becomes the duty of those, who may have had 
opportunities of appreciating its value, to endeavour zealously 
to promote its utility and growtli. In the several papers which 
I have published in the Lancet on this branch of auscultation 
I was mainly influenced by feelings of this description; and the 
same shall guide me, I hope, as well in the present, as in any 
other paper, that I may hereafter devote to the subject To 
every physician, who takes an interest in the science of his pro- 
fession, and feels a wish to promote and uphold its respec- 
tability, it must ever afford a peculiarly intense gratification 
to add to those records of improvements that are daily being 
made in this department of knowledge. And if I, who cannot 
but contemplate with delight the prominent position which my 
own countrymen are taking in the branch of medical literature 
VOL. xn. NO. 36. 3b* 






402 Dr. Nagle on Obstetric Auscultation. 

now before us, can oontribute anything useful to the general 
stocky my object indeed will be fully attained. 

I shall here briefly recapitulate^ what I have endeavoured 
to establish by those papers that appeared in the Lancet since 
1830 ; and then submit to the profession a few additional facts 
that may not be undeserving of attention. 

Auscultation affords but two signs of pregnancy : the pul- 
sations of the foetal hearty and a murmur^ tliat should, correctly 
speaking, be designated the uterine murmur.* 

The 6rst is absolutely unequivocal ; the second equivocal ; 
but, perhaps, the least so of those, that diould be considered as 
such. 

The pulsations of the foetal heart may be detected, at all 
events, between the fourth and fifth month, and vary from 120 
to 180 in the minute; though I have found them, and that but 
momentarily, to sink as low as fifty or sixty.f They remark- 
ably resemble the ticking of a common watch, and may be 
detected in various parts of the abdomen, but generally in 
the iliac regions, particularly during the advanced periods of 
pregnancy. 

They are, though occasionally nearly masked by the uterine 
murmur in the parts, where that is most intense, easily distin- 
guished by an experienced ear, especially if the cylinder be 
moved a little from the principal site of the murmur ; or wheq 
the foetus takes a roll in the womb. 

They are sometimes liable to be confounded with the pul- 
sations of the mother's heart ; but the distinction is drawn ^th 
facility by attending to the rhythm, and gradually moving the 
stethoscope towards the region of the parent's heart.^ 

In no case will the beatings of a foetal heart, when at all 
energetic, escape detection, if the examination be properly con- 
ducted, and the ear of the auscult^^oir be familiar with the 

III ■« I |l lll -t l.l H -^ri"^^! ' 

* Spt Lncft, December, 18. 1830, p. 89^. col. 2. 

t lb. Norember 13, 1830, p. 233. t lb. J«suvy 8, 1831, p. W. 



Dr. Nagle ok Obstetric Auscultation. 403 

rhythm and pectiliarity of sound. But this familiarity is abso- 
lutely requisite^ otherwise the examiner will be left in a state of 
perplexing uncertainty^ where a practised ear would scarcely 
experience the slightest embarrassment. 

By an intimate acquaintance with the nature of this sound 
we can readily ascertain the life or death of the foetus in the 
womb ; from which knowledge^ as I have already shewn^ we 
can derive vastly important practical benefits. We shall also 
experience no great diflSculty in detecting the existence of twins ; 
and, what I have myself found of the utmost, the most gratify- 
ing, practical advantage, we can, in most cases, easily discover 
the nature of the presentation.* 

The other phenomenon, the uterine murmur, I have shewn 
to be of considerable importance to the scientific practitioner 
in midwifery. It is the first of the two stethoscopic signs 
that occurs; and may, in vigorous constitutions, be detected 
about the third month.t It is not in the least aflfected by the 
life or death of the foetus in the womb ; and is quite independ- 
ent of the foetal circulation. Its principal site is invariably in 
the lateral regions, along the course of the lateral uterine ar- 
teries ; commencing, apparently, opposite the space between the 
anterior spinous processes, and closely to die iliac arteries.^ 

It should not be sought for in the anterior parts of the ob- 
domen; as its occurrence there never happens, unless some 
branches of the lateral uterine arteries should extend across in 
an unusually enlarged state. This we can easily verify by 
ilaoving the stethoscope gradually from die median line towards 
tibe ilium ; for thus we shall find the murmur to increase in in- 
tensity, as we approach the latter. 

It is frequently detected in both iliac regions at the same 

* S«e Lancet, December, 24Ui, 1831, p. 449, el t^q, 

t \ beg to be coniidered t& offering no decided opinion on this point. I think 
it might be discorered even earlier than the third month ; but as I am t ndavooriog 
to avail myself of every opportunity for determining the question, 1 may hereafter 
be enabled to speak with more conSdence on this subject. 

X See Lascet, January 8th, 1831, p. 497. «t leq. 



404 Dr. Nagle on Obstetric Auscultation. 

iime,* though usually louder on one side than the other ; and by 
repeating our examination^ we shall often hear it on the side^ 
where, in our previous inquiry, we could not, perhaps, dis- 
cover a vestige of it. To this fact I would beg leave to invite 
the attention of those, who would persuade us that the placenta 
must be the seat of this importaut phenomenon. And now let 
us dwell a little on this controverted point 

All must agree in the truth of the following propositions : 
1st. Experience shews that the placenta is liable to be attached 
to the uterus anteriorly, or posteriorly ; laterally, superiorly, or 
over the os uteri. Its place of implantation, therefore, is 
variable. 2nd, Tlie principal site — and this is the important 
point to be attended to — of the uterine murmur can never be 
detected, except in tlie lateral regions. Its situation, conse- 
quently, is invariable. If, th^n, the seat of the murmur be in 
that part of the uterus to which the placenta is attached, it 
should vary with the varying situation of the placenta. But 
it never does. Consequently, it is but reasonable to infer,' that 
the murmur is not seated in the placenta. Besides, have we 
it not — modified, no doubt — where there is no placenta ; as when 
the uterus is enlarged by disease, and the vessels carrying an 
unusual quantity of blood to the point of irritation ? This I 
was once enabled to show satisfactorily by a very interesting 
case.f It has also been found, that, after the placenta was 
removed, and the uterus resumed a distended condition, the 
murmur re-appeared. Where then was its seat ? 

Every observant and reflecting physician, who has acquired 
any experience and accuracy in obstetric auscultation, will 
readily accord his assent to the correctness of the following 
statement. It is by no means ap uncommon occurrence, to 
hear the murmur, quite distinctly, immediately opposite the 
space between the anterior spinous processes; and yet, after 
delivery, to find the placenta situated high in the uterus ! It 
is no argument to say, that the murmur may extend so low 



• See Lancet, December, 1 8th, 1 830, p. 397. f Ibid. p. 399. 



Dr. Nagte on Obstetric AusctdttUion. 405 



•o 



from the placenta^ for I have already shewn, that if the mur- 
mur, heard so distinctly and at so remote a distance, were the 
effect of radiation, it should become more clear and energetic, 
as we approached with the stethoscope to the placenta, the 
supposed point de depart, or centre of radiation.* 

If the author of the work on obstetric auscultation, with 
whom chiefly I happen to be at issue on this point of doctrine, 
would be pleased to meet these facts and arguments in a 
manner satisfactory to the profession, I will be happy not only, 
to give up my own opinions, but even to excuse his, in my 
mind, unsuccessful attempt to throw discredit on the '' sug* 
gested r utility of being enabled to discover with the stetho- 
scope the nature of the presentation, and the existence of twins 
in the womb; to which advantages, he will admit, I had 
directed the attention of the profession long before his work 
made its appearance.f 

During the time I had been engaged in the treatment of 
cholera in the Townsend-street Cholera Hospital, and whilst 
superintending that in Kilkenny, I had frequent opportunities of 
observing the effects of that frightful disease on the foetus in 
the womb. I felt it fully a part of my duty not to be deterred 
from attending to this important feature in that awful visitation ; 
for in a Christian land, it is not unimportant to ascertain whether 
the life of the infant in the womb, notwithstanding the death of 
the mother, may not be still inextinct in a malady, which, in 
many cases, ran a course so rapidly fatal. The result of my 
experience is the following. 

In every case of profound and perfect collapse, the life of 
the foetus in the womb was destroyed long before the death of 
the mother. This, by minute investigation before and imme- 
diately after the death of the parent, I satisfied myself of in 
numerous cases, as those who saw me make the examinations 

* See Lancet, December, 1830, p. 397, tt Mf. 

t See Lancet, Janaary 8th, 1831, p. 501 ; December 24th, 1831, p. 449» 
$tuq. 



406 I>r. Nagle on ObsMric AuscnUaMon. 

are well aware. Long before the stage of coUapae was com- 
plete, the uterine murmur ceased to be heard : but the life of 
the foetus has not been destroyed by the disease, when that was 
arrested before the collapse made any great progress. This 
was satisfactorily demonstrated, not only by stethoscopic investi* 
gation, but by many cases of pnemature confinement that oc* 
curred during that period. When the lives of the mothers 
were preserved by arresting the disease in its early stages, it w&s 
gratifying to have been enabled to assure them that their in&nts 
were ttill alive. 

Reflection will point out many ways, in which the know- 
ledge, I am endeavouring to inculcate, might be made most 
usefully available. The following may be considered aa no 
bad iiistance of it. An intelligent friend of mine was consulted 
by a female, not long in town, and then appearing to be affected — 
as she would fain persuade people to think — with some symp- 
toms of dropsy. He suspected the nature of the case, but could 
get no vaginal examination. He wished me to examine this 
person, and had a friend of his present, who, I believe, had 
seen the patient before, but did not consider it a case of preg- 
nancy. We met It was with difficulty we prevailed on the 
patient to allow an examination with the stethoscope even. I 
instantly heard the pulsations of a foetal heart, and unhesitat- 
ingly pronounced it a case of pregnancy. One oftiie f^ysi- 
eians, though long in practice, was sceptical : I wished to re- 
move Ins uncertainty by getting him to apply his ear to the 
cylinder. The pulsations of the foetal heart were very energe- 
tic, add about 160 in a noinute ; whilst those of the mother were 
reniEirkably slow, not more than fifty. He could derive no 
information from the examination, as he was then unacquainted 
with die use of the instrument. No persuasion could induce 
tine woman to admit the posubility of her being pregnant : but 
the extreme repugnance, with which she permitted even the 
most delicate stethoscopic examination, would be sufficient to 
create a suspicion that she was not conscious of her own inno- 
cence. I requested of my friend to inform her, that I, at leasts 



Dr. Nagle on Obstetric Auscultation. 407 

had not the slightest doubt of her pregnancy ; and I even pre* 
dieted, what actually took place, that she would in a very few 
days retire into the country for the better concealment of her 
real state. 

To an inexperienced practitioner this case may be instruc- 
tive; and I have given it in the hope, that it may contribute to 
induce those, who have not practised auscultation, to familiarize 
themselves with the use of the stethoscope, by which only cer- 
tainty of diagnosis could be obtained in such a case. The foU 
lowing is another striking illustration of what I would inculr 
cat 

A female presented herself at the Dublin General Dispen^ 
sary : her appearance would indicate a dropsical aflfection. After 
a few questions I told her that I suspected she was pregnant. 
She peremptorily denied its possibility. I sought for, and rea- 
dily detected, the uterine murmur ; and again, with more confi- 
dence, repeated my suspicions, but she still persevered in her 
denials. To remove all doubt from my mind, I examined 
for, and easily discovered, the pulsations of a foetal heart, and 
told the patient that she was positively in the state I repre* 
sented. This I insisted on with so much confidence, that her ob- 
stinacy at last gave way ; and bursting into a flood of tears, she 
admitted the possibility of all I said being perfectly true. 

The practitioner in midwifery may infer from the case, with 
which I shall conclude this paper, what important service mi^t 
be derived from an accurate acquaintance with the use of the 
stethoscope in tiiat critical department of our profession. We 
are well aware that infants oflen appear to be still-bom, and 
are laid by as such, though the labour seemed to proceed quite 
favourably, and the attendant physician had most carefully dis* 
charged his duty. This calamitous result may be occasioned 
by the pressure exerted on the head at the moment of its es* 
cape ; or by other circumstances over which the physician could 
have no control. Auscultation, judiciously employed, would 
have shewn that, in many such cases, the foetus had probably 
enjoyed vigorous existmce a few moments previous to it|^ 



408 Dr. Naglc on Obstetric Avscultation. 

birth ; and thus the physician be encouraged to persevere in 
the use of eflScient means for restoring suspended animation. 
How many valuable lives may be thus preserved ! how grati- 
fying to the conscientious physician must success in his profes- 
sional exertions^ under such circumstances^ always be ! and bow 
simple are the means for the attainment ofjsuch encouraging in- 
formation^ may be thus satisfactorily illustrated ! 

On the 4th of October, 1835, I attended, in her confine- 
ment, Mrs. Cooney from Trinity College. Tlie labour pro- 
ceeded favourably, and the presentation was quite natural. The 
action of the fcetal heart, examined frequently, as is my custom, 
was ascertained to be perfectly regular, and retaining its energy 
undiminished; yet the child, when bom, seemed absolutely life- 
less ; and all appearances, combined with an intolerable foetor of the 
liquor amnii, which passed off as the head was emerging, were 
well calculated to leave on one's mind an impression, that the 
infant was dead for some time. Without the benefit of auscul- 
tation I should have been myself under a similar impression ; 
but from the regularity and strength of the heart's action about 
ten minutes before delivery, when I last explored it, I concluded 
that the vital spark could scarcely have been quite extinct. No 
benefit appearing likely to accrue from allowing the cord to 
remain any longer undivided ; and having rapidly provided for 
the mother's safety, I succeeded, ader nearly an hour's unre- 
mitting, because not hopeless, perseverance, in restoring the 
infant to vigorous animation.^ 

* 1 said that the poIsatioDs of the foetal heart can be detected, at all tvemts, be- 
tween the foarth and fifth month. In proof of this I am now enabled to state,, that oo 
the snth of last October I heard them so distinctlj in a female, who bad oooodTed 
on the 18th of Maj, that I am convinced I coald have discovered them long 
before. Thej were moeh slower than at a more advanced period, but perfectlj re- 
gular, and so verj distinct that I coald easily recognize them, thoogh the mother 
was standing when I made the examination. She mentioned that she felt the move- 
ments of the foetus daring the previoas fortoight. This, case will also enable ine» 
I expect, to give an opinion, with some confidence, on another controverted point-^ 
tiie period between conception and the oommenoement of labour. I lia?e alreadj 
ftrong, bat not decialfe, proof, thai thai period is 280 dajs. 



Dr. Gadecheng on the Phywdogy of the Hip Joint. 409 



Physiologie des Hitftgelenkes in ihrer 
Beziehufig ztir Lehre von der Coxarthrocace, Von Dr. 
B. Gadechens^ pract Arste in Hamburg. 
754^ Physiology of the Hip Joint, considered in Relation to the 
Doctrines of Hip Joint Disease. By Dr. R Gadbohens, 
of Hamburg. 

[Translated from the Zeitscbrift fur die Gesamrote MeJkioe. By S. Lenox L. 

BiooBR, M,B., L.R.C.SlI.J 

• 

No very deep knowledge of the doctrines hitherto entertained 
with regard to diseases of the hip joint is requisite^ to con- 
vince that they are far from having arrived at the grade neces- 
sary to an accurate science ; although much has been done to 
elucidate them, both in our own and in former times^ by the 
most distinguished practitioners^ still they are capable of 
being shaken in their fundamental principles by every severe 
attack. 

The systematic representations of Rust had deservedly ob- 
tained the approbation of the medical profession on account of 
their exhibiting the phenomenon, how under a deceitful exte- 
rior, internal disease might be concealed. 

English surgeons also (Falconer, Crowther, and Brodie, 
had with their usual practical sharp-sightenedness, got rid of 
many diagnostic diflSculties, and by. their pathologico-anatomical 
examinations, explained more clearly the seat of the lesion 
and the morbid products during the progress of the disease, 
Still much remained to be cleared up and unriddled by Fricke's 
laudable researches, to which our gratitude is due, because 
^y have freed those dogmas from the fetters of authority, and 
have first excited serious doubts on the correctness of former 
views and representations. 

We cannot wonder that Fricke did not succeed in banish- 
ingall obscurity from this his self-chosen path, or in reconciling 
what ia contradictory in his observations to the observations of 

VOL. XIL NO. 36. 3 P ' 



410 Dr. Gadecliens on the Physiology of the Hip Joird. 

his predecessors^ since we learned the valuable discovery of 
Edward Weber, of the hitherto totally disregarded eflect of 
atmospheric pressure on the hip joint. In vain might the sur- 
geon exhaust his talents in attempts at explanation, so long as a 
physiological problem of such consequence was withheld from 
his eyes. But by this discovery the way is opened, and the 
path indicated, by which we may enteron a territory from which 
we were hitherto partially excluded. Time will shew, if we 
shall make a proper use of the clue which Physiology has pre- 
sented to our hands, from the cornucopia of her newest dis- 
coveries. 

For this reason we have been induced to give a fragmentary 
description of the influence which the discovery of Weber has 
had on some striking points of the pathology of the hip joint. 
With justice may it be said, that with the discovery of Weber, 
a new and fortunate era commenced for the doctrines of hip 
joint disease. Weber proved by simple and convincing expe- 
riments, that it was not the muscles and ligaments, as was for- 
merly supposed, which preserved the head of the femur in 
contact with the acetabulum, but that the acetabulum being 
closed by the head of the bone in an airtight manner, the femnr 
was held suspended by the atmospheric pressure, just in the 
same manner as the sucker is in a syringe, the anterior opening 
of which is closed by the finger. Hence all the muscles and 
ligaments about the joint, even the capsular ligament, may be 
cut through, without the weight of the leg causing the head of 
the femur to recede in the slightest degree from the acetabu- 
lum ; whilst on the contrary, when all the ligaments and muscles 
are left entire, the head of the bone will sink from three to four 
lines out of the acetabulum, if the atmosphere pressure be per- 
mitted to act on the upper surface of the head of the femur, by 
boring a hole from the inside of the pelvis into the joint. Ex- 
periments in vacuo* have further proved this fact, and have put 
io flight every doubt which could be entertained. 



..A 



* MuUer*! llandbuch d«r Plijiiologie* voLiK p. 124* 



Dr. Gadecbent on the Physiology of Uie Hip Joint. 411 

Weber himself bas remarked, tliat his discovery might be 
made use of for the explanation of one particular symptom of 
hip joint disease, viz. the elongation of the affected limb. He 
meant that form of idiopathic hip joint disease, in which, in per- 
sons otherwise healthy, without any external cause, tl^e thigh 
bone sinks out of its socket, by which, at first, a remarkable 
elongation of the diseased limb occurs, and evident limpings (as 
in Fricke's Coxalgia, sensu stricliori,) this elongation is produ- 
ced in this manner, eitlier through the action of the secreting 
vessels depositing a watery fluid or a firm substance in the ca- 
vity of the joint, which causes that tlie femur should be de- 
pressed from the joint in the proportion of its increase, and that 
it should smk outwards by its own weight, without the ligaments 
being capable of giving the slightest opposition. 

That this pathological deduction, volunteered by Weber, is 
not very striking, Lauer* haf evinced, and has well remarked 
that in such process the thigh bone by no means sinks out of 
the acetabulum by its own weight, but is pushed out of it by a 
process altogetlier peculiar ; for a watery fluid or a firm sub- 
stance exuded into the joint, would act quite diflerently from 
air permitted to enter through a hole in the acetabulum. The 
latter is in connexion with the whole atmosphere, and presses 
the head of the femur with the same force outwards, as it did 
before the hole was bored, in the contrary direction : but in the 
exudation this is not the case : here the operation of the at- 
mospheric pressure was only modified and not removed. Other 
objections may be made to Weber's conclusions. According to 
bis own work, the acetabulum with its ligamento-cartilagi- 
D0U8 border, describes only in one direction, viz. from before 
backwards, a peHect half circle of 180 degrees, but in every 
other direction a smaller segment The edge of Uie acetaba- 
lum is placed at farthest only on the greatest circumference of 
the spherical head of the femur, and as it does not project out 



* See fccond ?ol, of Zeitchrift fur die geammte Medicio. 



412 Dr. Oadechens on the Physiology of the Hqf JoifU, 

over thi8y it cannot at all assist in retaining the head df Ae bone 
in the socket. Every force therefore, which expels the head of 
the femur from the acetabulum,. must, since it removes the con* 
' tact of the edge t>f the acetabulum, from the greatest circum- 
'ierence of the bead of the femur, bring. it always to a smaller 
segment of the egress of the acetabultim. Also in proportion 
as the head of the femur is forced out, there exists between it 
and tlie border of the acetabulum, a greater or less empty space 
of a circular form, into which the greater part of any watery 
'fluid in the joint must flow of necessity, whereupon also the 
pressure of the atmosphere, without any activity of the muscles, 
must instantaneouely drive back the head of the femur into the 
bottom of the acetabulum, consequently the capsular membrane 
must be perfectly full of watery exudation, before in this manner 
a permanent elongation of the limb can occur. It follows from 
this explanation, that Weber must have entirely disregarded 
the share which must be allowed to the activity of the muscles^ 
as those who are aflfected with this slight degree of sufiering in 
the hip, and who are accustomed to go about for a long time, 
find in consequence, the femuro-pelvic muscles constantly in a 
'state of powerful contraction. We can imagine thus, that by 
the atmospheric pressure acting at the same time, a vei^ small 
proportion of muscular contraction would suffice to draw back 
the head of the femur into the acetabulum, and we can also 
think, on the same grounds, that it could only be by nearly 
perfect -filling of the capsule of the joint with exuded moisture, 
that any lasting elongation of the limb could occur. 

If we cannot unconditionally concur in Weber's pathological 
' conclusions, this however cannot do the slightest prejudice to Ae 
weighty influence of his discovery in general upon pathology. 
For, first, from his experiments it is undeniably proved, that 
when there is no aflection of the joint, and when there is only 
disease of the muscles or ligaments, be it of what kind it may, 
by no means can any separation of the head of tlie femur fh)m 
the acetabulum, and a consequent elongation of the leg« be 



. Ebr. Gadedieti8 on the Physiologylof the Hip Joint. 4 13 

efiected. Even perfaol panlym of Ae muscle cannot produce 
ity a fact which any one can eonvince himself of^ if he dbonld 
ftill hold such procJ necessary. 

The eTideoce which Fricke has given on die same disease, 
to which he has applied the name of Caxalgia Sensa Propria, 
IS no longer of any avail in the present state of knowledge, but 
-most be replaced by other proper to the times. The experi- 
ments of Weber with the above mentioned limitations o£fer 
diemselves as simple and uncontradicted, and one might in "die 
greater number of cases of coxalgia, in the sense in which 
Fricke applies dist term, form a tolerably correet diagnosis, 
when he £dt disposed to account for the lengthening of the 
limb, either by a serous or purulent efiusion,*or even by an 
extravasation of blood into the joint Collections of this kind 
are also formM by the abundant communication between the 
bursa iliaca and the joint, and by the common occurrence of 
dropsy in the bursa ; by the transference of the same to the hip 
joint, the occurrence of dropqr> or of very marked symptoms of 
disease of the joint, is more easily discovered. Two arguments 
appeared to be opposed to tlie theory of Weber : vis. 1st, the 
pretended results of experiments instituted by Fricke on sub- 
jects: and 2nd, the oonstandy remarked wasting of ^ muk^Ies 
of the thigh observed by him in cases of coxdgia sehsn stric* 
tiori, which will not permit us to exclude altogether the 
sympathy of the muscles. Whatmay be the valae of the ^peri- 
flMnts of Fricke practised on subjects, is not clearly intelligible, 
•which consisted of .freeing the head of the femur from its con- 
nexion with the joint, by a simple indsion,' and having wrapped 
it in linen, so replacing it ; or those of Weber in which the 
head of the bone was not surrounded, but the acetabulum filled 
vrith charpie> for in measuring the Kmbs in bodi of those cases, 
no difierence could be found. For as it is proved that by the 
simple access of air to the joint, the bead of the femur is 
-separated three to four lines from the bottom of the acetabulum, 
land the whole leg is even so much elongated, so w^ cannot 



414 Dr. Gadechens on the Physiology ofihe Hip Joint. 

conceive but that if in these experiments the same apace whkii 
was filled with air were filled by a firm body, that there would 
not be an equally remarkable elongation discoverable by mea- 
surement The difference appears to arise from this, that the 
experiments of Weber were made on bodies, the inferior parts 
of which were hanging down; whilst those of Fricke were 
made on bodies placed in a horizontal position. In the latter 
cases the limb could not be acted on by its own weight, but on 
the contrary, being brought into the same horizontal position 
with the other, whilst the artificially enlarged head of the femur 
whidi it would be now impossible to return into the acetabu- 
lum, would occupy an unaltered situation, probably externa 
and superior against the edge of the acetabulum ; a circum- 
stance which would make these different results of measuremeot 
easily intelligible. The wasting of the inuscles, however, whidi 
Fricke gires as the constant and characteristic symptom of his 
coxalgia, and sometimes a peculiar softness of the muscles to 
the touch, contains nothing dissonant to the etiology of Web^V 
hip joint disease ; however, in place of a primary symptom, as 
declared by Fricke, it should be taken as a secondary one^ as 
the patient is compelled to support the body on the sound 
limb habitually, and only to draw the affected one, which does 
not offer him proper security, after him ; on which account its 
muscles from inaction, necessarily degenerate into a state of 
softness, which is much increased when a quantity of fluid 
is collected in the joint, and perhaps aggravated by the unaccus- 
tomed distention which the muscles suffer. En passant, we 
may remark, that this peculiar and equally doughy softness 
of the muscles, may find its explanation in a sentence of 
Weber's, which may here be introduced. In his medianism of 
the joints,' he says : *^ The condition of the muscles during life 
alternates between the extreme of stiffness and the extreme of 
softness, much more than after death. Also after death the 
difilerence between the muscles during the rigidity which suc- 
ceeds it, and after that is passed, is very great : during life, on 



Dr. Gadechens on the Physiology of ilie Hip Joint. 415 

the one hand, the muscles can, during a violent effort, attain^ 
for a short period, a stiffness and hardness far greater than that 
occurring after death, and which makes them like to the bones : 
on the other hand, their softness, when perfectly relaxed during 
life, exceeds in a similar ratio their softness after the stiffness of 
death has passed. 

It may further be inquired ; if an elongation of the leg never 
can arise through simple atony or paralysis of the muscles, 
without there being at the same time an affection of the joint, 
how on the contrary can it have any connexion with the shorten- 
ing of the limb ? Can this be effected by simple sympathy of 
the muscles, or by a condition of permanent contraction, or by 
spasm of the muscles ? 

* So long as the operation of the atmospheric pressure upon 
the hip joint was unknown, and the generally received opinion 
was, that the femur was held suspended in the acetabulum by 
the muscles and ligaments, and that the head of tlie femur 
possessed a certain space for motion, which was decreased by 
every action of the muscles, and increased by every relaxation ; 
there was nothing unnatural in the theory that a simple condi-^ 
tion of irritation of the muscles might produce a permanent 
shortening of the leg, and we need not wonder that the muscles 
were supposed to play the first parts in the shortening occurring 
in hip joint disease, as well as in contusion. Weber^s re- 
searches have also instructed us better on this point, for if the 
head of the femur be in a condition to close the acetabulum in 
an air tight manner, then there can remain no unfilled space 
between the articulating surfaces of both, as each must move on 
every part of the other, for we cannot take into account the 
perfectly unmeasurable space which the synovia occupies. 
That this was really the case, Weber convinced himself by 
making several sections through the whole joint in various 
directions, and also by taking casts of the head of the femur, and 
of the acetabulum in plaster of Paris. The solid half sphere^ 
taken as a cast from the head of the femur, fitted so exacdy in 



416 Dr. Gadecbetis oit ih^P/nf^ogy ofi/te Hip nhmU 

the bollow imprestkHi from tbe acetabulum, wben the uneven* 
ness arising from the cavity for tlie ligameotutu teres had been 
taken away, that a small slip pf pi^per prevented iq a remarkable 
manner the entrace of the artificial head ipto it, which would 
not be the case if both surfaces of the joint were not segments 
of equally large spheres. 

Hen^ we can no loi^g^r speak of space easting between 
tbe head of the bone and tbe acetabulum, which^ on Palletta\ 
authority, was regarded as proved, and shortening by tbe mere 
action of the muscles could only be conceivable by a conside- 
ration of the practicability of the cartilages covering their sur- 
feces being compressed, as Fricke, Wemher,* and others have 
thought to be the case. Yet if any one would consider that the 
thicl^ness of those in most places is only one line, in a few a line 
and a half, and at the most three lines, for both cartilages gor« 
udered togiether^ and if he should try to compress pieces of 
cartilage which were cut off* between two masses of wood or 
glass, and found the remarkable resistance which they give to. 
great pressure, then would he be very little inclined to lay 
great stress to attributing the ^oKening to this cause, and par^ 
ticularly if be had experienced how uncertain -measurements 
are in living persons, when it concerns so small a space as one 
line^ or half a line. Wherefore, the muscles have just as much 
power by their contraction alone, to produce a shortening of ti^ 
limb> as on the contrary, by mere relaxation to produce an 
elongation. But even in organic injuries of tlie joint, in real 
hip joint disease, it will depend entirely on the situatipn'aD4 
the circumference of the lesion, whether Softening may follow 
it or not. We liave seen that the head of tbe femur and the 
acetabulum are closely attached to one another, like an hemi* 
sphere closely and accurately embraced by a capsule. Such an 
hemisphere- can only sink deeper into its capside by a diminu^ 
tiqn.of its who^ volume, or 4he capsule must be eulargedy 

• f r » I ■■ ' t , 

— *— — ^^ III ■»■■> m \ I m I fi ■II pit m^fmm»m ■ i i i — ^fc^^ > , , , 

* See achmidt'* JahibmcbOT, vok ^; P^ )» ^ 108. 



Dr. Gadechens on the Phyriology of tie Hip Joint. 417 

6very paH» Any partial alteration in tbe relative dimenaions 
of bothy would only remove in some situations the motions of one 
surface on the other, but would not cause the entire convex 
surface to pass deeper into the concave. Thence it would be 
possible to remove a large segment of a sphere from the head 
of the femur, as in Fricke's fifth experiment, or a similar por* 
tion from the back part of the acetabulum, without causing by 
this means any shortening, and consiequently the destructive 
caries in hip joint disease must have already included the en- 
tire superficies of the head of the femur, or of the acetabulum, 
before evident shortening can be found as the effects of it. 
This agrees perfectly with the experience of Rust, and of many 
others, who only found shortening in rare cases, and such as 
might be considered more properly as exceptions to the first 
stage of hip joint disease; yet they regard it as a constant and 
necessary symptom of the earlier stages of the disease, and that 
it never is absent where the diseased limb, on a superficial ex* 
amination,appear8 longer than the sound one : thus anyone might 
imagine at a first glance these two declaratiqns are so evidently 
opposed, that if one of them stand, the other must necessarily 
fall. Both, however, can be associated together, without dif- 
ficulty, as we shall presently shew ; and we have only to discri- 
minate accurately the observations from which these two opi- 
nions have been deduced, and avoid transferring the characters 
6f one set to the other. It is well known that English sur- 
geons (Falconer, Crowther, and Brodie) first drew attention to 
the remarkable protrusion or sinking of the pelvis of the affected 
side in hip joint disease, and distinguished from real, an 
apparent elongation of the limb, arising from this oblique posi- 
tion of the pelvis. Brodie endeavoured to determine the real, 
by measuring the distance between the anterior superior spine 
of the ilium and the patella, which measurement Fricke 
modified in a most useful manner by selecting in place 
of the patella, the external inferior condyle of the fibula, 
which aflfoi^ed a less moveable and more equable point 
VOL. XII. NO. 36» 3 a 



418 Dr. Gadechens on the Physiology of the Hip Joint. 

for placing the measuring instrument upon. By this improved 
method, and by the most careful examination of each indivi- 
dual case, Fricke obtained results always the same, viz. : that 
in apparent elongation of the limb, there was always real 
shortening, which amounted nearly to the same extent as the 
apparent elongation. 

This fact, to that period overlooked, has been placed by 
Fricke*s numerous measurements beyond all doubt, and now all 
that is requisite^ is a correct and physiological explanation of 
this phenomenon. 

Fricke looked upon an increased contraction of the muscles 
of the hip, to which they are excited by the continual pain in 
the joint, and by means of which the head of the femur is 
pressed more powerfully into the acetabulum, as the cause of the 
shortening which is found. On one side, however, there is op- 
posed to this what we have said above with regard to the connexion 
of the head of the femur to the acetabulum, and also the slight 
compressibility of their cartilaginous envelopes, and on the oUier 
aide, that in all cases of hip joint disease, a permanent state of 
contraction of the muscles has not been observed; for how 
would such permanent contraction of the muscles agree with the 
great depression of the pelvis on the affected side, which 
we concur with Brodie in considering, to be, without doubt, a 
passive state, from the usual gate and limping of persons 
aflSicted with morbus coxae, both of which are attempts to avoid 
every muscular efibrt of the affected leg, and to throw the whole 
weight of the upper part of the body, and every motion 
demanding exertion on the sound limb. Also the diminished 
rotundity of the muscular parts about the joint, and the well 
known state of relaxation of the glutei muscles, are not favour- 
able to this opinion ; finally, it is unlikely, that by perfectly 
different degrees of intensity of inflammation and of pain, at 
different periods, and in different subjects, that the muscles 
should ever find themselves in an over-excited condition. Be- 
sideq the feeling of contracUon in the muscle, to the band 
of the examiner, can be easily explained, for at the very moment 



J 



Dr. Gadechens on the Physiology of tlie Hip Joint 419^ 

oF the examination^ the pain which is caused or increased may 
give rise to an instantaneous contraction of the muscles^ through 
recurrent branches of the inflamed nerves when touched ; this^ 
however, proves nothing with regard to a permanent and pre- 
existing state of contraction. 

All these grounds are more particularly supported by this, 
that every phenomenon of real shortening with apparent 
elongation, explains^ itself most perfectly in another way, by 
which we can abstract the greatest part from the agency of the 
muscles. Fricke has already drawn attention this, that the ap« 
pearance can be produced just as well in persons in health, and 
that any one can remark it easily in his own person by holding 
both legs together, whilst he endeavours at the same time to 
make one leg longer than the other, by which act the appa- 
rently elongated limb will actually measure three or four lines 
shorter than the other. " This phenomenon," proceeds Fricke, 
'* has the same cause as in morbus coxse, inasmuch as by the 
effort to make one leg longer than the other, all the muscles in 
the thigh of the former are placed in a state of activity, and by 
the depression of the pelvis the head of the femur is driven 
with still greater force into the acetabulum.*' But it is not 
alone in healthy living men, but also in subjects, where no con- 
sideration of muscular action can enter, that this experiment 
can be illustrated, with the same results^ if one of the lower ex- 
tremities be fixed whilst we lay hold of the knee and heel, and 
raise it upwards whilst kept in a perfectly extended state, 
slowly beside the fixed extremity, during which, however, even 
the slightest bending of the knee, or any turning of it inwards 
must be carefully avoided. Then it may be seen that in the 
same proportion as the crest of the ilium on the shortened side 
is raised higher, the opposite one sinks down towards the fixed 
limb, and gives the same result on measurement of the elongated 
side from the anterior superior spine of the ilium, to the^exter- 
nal condyle of the fibula, as it does in healthy living persons, 
viz. a shortening of from three to four lines in comparison 



420 Dr. Gadechens ofi the Physudogy ofilie Hip JouU** 

with the length of the leg in the ordinary position of the pelvis. 
That there is no forcing of the head of the femur against the 
bottom of the acetabulum in this experiment, but only a 
simple lateral inclining of the pelvis around the head of the 
femur of the fixed leg, stands in need of no proof. If any 
one^ however^ was determined to retain the idea of violent 
pressure into the hollow of the acetabulum causing shortening, 
then such a person would find it sooner in this experiment oa 
the apparently shortened side, as here the obliquity of the pel- 
vis is caused by the powerful shoving upwards of the whole ex- 
tremity against the pelvis. Here, however, not only is there 
no shortening of the space between the spine of the ilium and 
the external condyle of the fibula, but on the contrary an elon- 
gation, and this Condition, which was over-looked by Fricke, 
gives us the best explanation of the whole phenomenon. It is 
thus that this happens, by every inclination ,of the pelvis, the 
whole ilium of the depressed side comes nearer to the trochan- 
ter major, whilst on the opposite, the ilium recedes in the samei 
degree from the trochanter major of the other leg, by which 
circumstance an elongation occurs here, and a shortening there, 
of the space between the trochanter and the spine, and conse- 
quently the same must occur in the whole limb. This process 
may be rendered more evident by considering the head of the 
femur as the centre, and the leg itself as the radius of a circle, 
the periphery of which marks the distance of elongation which 
would be described by a lateral rotation of the heel in the ho- 
rizontal position of the body. The anterior spine or any other 
point of the half pelvis would stand inside this circle near the 
centre, and thence, according as the leg was moved to one, or 
the other side of the circle, at one time it would approximate to 
the under side of the leg, at another distance itself from it, by 
which means the space in the first case would be shortened be- 
tween both points, in the latter increased* Now what can be 
effected by lateral motion of the leg in its socket, whilst the 
pelvis is fixed, can also be accomplished whilst the legs are 



I>r. Gadechens on the Phjfriology <f the H^ Joint. 421 

fixed by lateral twisting of the pelvis on the tbig^ bones,, 
fdthough on account of the circumscribed motion not to the 
same extent Hence it happens that the real shortening which 
is always found with apparent elongation of the leg» and at the 
same time on the opposite side, the real elongation with appa- 
rent shortening, alters only so far by an action of the muscles, 
as can be produced by inclining the pelvis obliquely to one side 
or the other by the action of the muscles during life; but the 
principal cause of this appearance is to be found in each lateral 
motion of the pelvis, or in other words, in the altered position 
of the portions of the bone of the pelvis to those of the inferior 
extremities. 

That this fact, which has hitherto been disregarded in an 
extraordinary manner, cannot remain without in&uence upon the 
formation of doctrines of hip joint disease in general may be 
readily imagined. The first and proximate argument which 
we would deduce from this is, that in all cases where already 
in the first stage of morbus cox®, a depression of the pelvip 
occurs on the suffering side, also a real shortening of the 
aflTected leg is to be found, and that thence the assertions of 
Rust and Fricke, so contradictory in appearance, are only to be 
distinguished into those cases in which obliquity of the pelvis has 
not appeared, and those in which it has, in order that they may 
coincide without false conclusions with one another. The dis* 
tinguishing of those different cases is of so much the more con* 
sequence, as it appears from Frieke's observations and accurate 
measurements, that the obliquity of the pelvis in morbus coxae 
is much more frequent than Rust and other German surgeons 
are disposed to consider it, and that it is not to be regarded as 
a rare exception* Perhaps Fricke saw it abundantly because 
his examinations of this condition were principally made in 
hospital practice, and also almost entirely on persons of the 
labouring class, who, when the inflammation did not come on 
yery severely, which it is well known is seldom the case, pur- 
sued, as is invariably the case, their ordinary avo(»tions, after 



422 Dr. (jradechens on the Physiology of the Hip Joint. 

the access of the first symptoms had passed^ and engaged in 
laborious occupations, by means of which the promotion of a 
depression of the pelvis on the diseased side must be necessarily 
favoured. If on the contrary the patient can from the com- 
mencement keep his bed, and observe a quiet, horizontal posi- 
tion, the pelvis can hardly be altered in position, to which 
Brodie has already drawn attention : " that the apparent elonga- 
tion of the extremity, is very soon lost by the patient being kept 
in a perfe<^y passive condition." 

But it is not alone in the theory of morbus coxas, but also 
in that of contusion, that it is of importance to know that a 
simple change in the position of the pelvis with regard to the 
inferior extremities, or of those to the pelvis, is sufficient to 
produce a so called real shortening of the extremity. Con- 
tusions occur to the .thigh principally on the outer or posterior 
side, and shortening of the extremity, whether apparent or real, 
which appears hitherto not to have met with due consideration, 
is a very frequently accompanying symptom. The opinion 
formerly given, and which was regarded as satisfactory, namely, 
the pressing in of the head of the femur into the acetabulum by 
increased muscular contraction, can avail as little here as in the 
first stage of hip joint disease. On the other hand, the discovery 
of a depression of the pelvis on the injured side, [compare this 
paper with Guerin, vol. ii. p. 224,] or an external abduction of 
the teg, without inore, is sufficient to unveil the cause of tlie 
shortening, and we have only to determine whether the lateral 
approach of the pelvis and of the inferior extremity be caused 
by muscular contraction; that is, whether it be. active, or, accord- 
ing to the opinion of Brodie in morbus coxas, a passive sinking 
down of the affected side ; because the male patient bears the 
whole weight of the body on the sound extremity, in order to 
diminish the pain, and the female patient takes advantage of iU 
in order to support the equilibrium of the body. 

Sufferings from contusions on the outer side of the leg Will 
often be explained by tumours and abscesses, consequently such' 



Dr. Gadechens on the Physiology of tlie Hip Joint. 423 

occurrences in the neighbourhood of the joint must not be 
overlooked. For want of individual experience^ I roust leave 
the application of this subject to those who have enjoyed 
opportunities more abundantly and accurately of proving those 
points by clinical observation^ and which I have only spoken of 
in a physiological respect 

To induce further practical research^ we will only remark^ 
that hitherto every one was deceived when he considered the 
actual length of the unaffected side, when previous obliquity of 
the pelvis had existed^ as the normal length of both limbs; for 
as we have shewn, also on this side by the altered position of 
the pelvis, the ordinary relations of the dimensions is modified, 
as is exemplified in the apparent shortening of the sound limb, 
which most frequently is the case, and where constantly real 
lengthening is to be found. Above all, this limits in a certain 
degree the value of general measurements ; for it never will be 
easy to calculate the natural length of the extremities before 
the pelvis became oblique, after that occurrence has taken 
place, particularly if already, in consequence of the process of 
inflammation, changes of form may have occurred to the aceta- 
bulum or to the head of the bone, which may have their share 
in the production of real shortening. However, if the mea- 
surements be made with circumspection and prescience, it will 
always be a diagnostic assistance of the greatest consequence, 
and it might, if pursued after the method indicated by Fricke, 
possibly, give unerring results. 

In conclusion, I must speak my conviction, that after the 
disclosures, which on the part of physiology we have given on 
this subject, a perfectly new course of pathological research is 
required, in order to raise our theories of hip joint disease to 
the height of a perfect knowledge, of which is is now capable, 
and which is now more than ever necessary. Particularly is 
there urgent necessity, that at last by accurate diagnostic signs 
the diseases of the hip joint should be distinguished from those 
of the parts surrounding it, as well as those diseases of the 



42!4 Dr. Giidechens on the Physiology of the Hip JaitU. 

joint which are not inflammatory from genuine morbas coxae — 
a wide field for surgical Inquiry^ and in which a rich reward is 
to be earned. 

May these lines^ which proceed from the pm-est motives of 
afibrding inFormation, serve at the same time as a challenge to 
the honoured editor of this periodical anew to turn his particular 
attention to a portion of pathology which^ under far more diffi- 
cult circumstances^ evidently demanded, and always was treated 
by him with attention not to be mistaken. The valuable oppor- 
tunity which presents itself of observing diseases of the hip in 
our General Hos ital, (Hamburg,) allows us to hope still more 
useful results, from a recurrence of observations on diseases of tb« 
hip^ with regard to the modifications of the physiological foun- 
dations, now become necessary; as well as from similar re- 
searches in many other clinical institutions^and we may rely oa 
a careful attention being paid to the cases which may occur, for 
the advancement of science, so much the more certainly, as the 
surgical section has never shrunk from its engagement, but has 
always in the most praiseworthy manner pronaoted the cause of 
knowledge, and the science of medicine, after a due regard 
had been paid to the patients intrusted to its charge. 



BIBLIOGRAPHIC NOTICES. 



'Mr. Faussbtt*8 R(^,ply to the Medico- Chirursieal Reviewer, 
with Observations on a certain Form of hpigasiric Chro- 
nic Congestion: 

The editor of the Medico-Chirurgical Review has done me ' 
the honour of noticing my pa|:)er on " Violent Pulsations in 
,the Epigastric Region^ and their Treatment y ^ yAiwh appearecl 
in the Dublin Journal of July last. My reviewer is of opinion 
that I have ofTended against the laws of brevity : had it not 
been my wish to avoid obscurity, while it was my object fully 
to develope some views upon the nature and treatment of 
epigastric pulsations which were not previously entertained, or 
at least published, I might have been more concise. My re- 
viewer, however, ^^quarreW^ witli me, because 1 have not walk- 
, ed implicitly in Baillie s footsteps, but dared to describe with 
Imth what 1 had myself observed with attention, departing 
from the path of " other physicians and surgeons who must 
have had opportunities of verifntng the general correctness of 
At5(BailIie s) obser cations J^ To appear as wise as Baillie, and 
to get credit for thinking and seemg all that Baillie thought 
and saw, are, no doubt, high pretensions, and appear to consti- 
tute my reviewer's ne plus ultra standard of perfection, as well 
as a pinnacle to which his ambition soars. To wander from 
such high authority looks like innoimtion, it is an affectation 
of discovery, and savours strongly of arrogance. Did Baillie 
recognize epigastric pulsations in persons in the middle periods 
of life, and never at a period under thirty ? My reviewer would 
rather take Baillie's word /br ages, than the written testi- 
mony of a parish register. Should a greater number of females 
than males present themselves with epigastric pulsations, my 
reviewer would be ready to declare, that half of them mistook 
their sex, and were — *' Highlanders with petticoats prolong- 
ed,** hecause, forsooth ! Baillib says, ** the complaint is more 
commonly to be found in men than women." '^ But," quoth 

VOL. XII. NO. 36. 3 H 



426 Bibliop^ap/iic Noiices. 

Baillie, " I am unacquainted with any means oicuring this af- 
fection." How will our critic act now ? Think you that he 
has lost his sense of politeness, and will be found differing from 
the learned ? No ! he prefers even ignorance in good compijmy 
to knowledge emanating from an humble source, and would, 
therefore, " pause before he applied the remedies advised,** 
because he thinks them " powerful." I admire my reviewer's 
prudence as well as respect for the memory of Dr. Baillie, 
and as a junior member of the profession to which I have the 
honour to belong, I trust, I am not, myself, wanting in a due 
deference for authority, or in a suitable regard for the opinions 
of ray superiors, yet *^ JSTullius addicttu Jurare in verba ma- 
gislri ;" if I chance to meet with a woman of twenty y* the 
subject of epigastric piilsations, I would not like to insist upon 
her being thirty at least, merely because Baillie fixed that age 
as a limit of life for the occurrence of the affection ; and so with 
respect to other diflferences of opinion, where conscience, and 
the evidence of my senses, led me to dissent from high autho- 
rity. Again, I would find it hard to admit, that Baillie^s not 
venturing to account for the phenomena of epigastric pulsations, 
should inculcate a spirit of supineness in us, or put a bar upon 
our investigations, or that his being ignorant of a cure, should 
necessarily entail a like ignorance upon all posterity. But let 
our critic proceed. 

" We suspect that the subjects of the affection which Mr. Fnustet 
describes, have been principally females [not Highlanders ? qnere ?] 
affected with those anomalous hysterical symptoms which ape all ma- 
ladies." 

My learned critic's suspicions are at varience with his own 
quotations ; but let him continue. 

" In them too, of course, there is epigastric tenderness ; we say of 
course, because such patients have tenderness in any part to which 
attention is directed." 

1 beg to assure my learned reviewer, that with such purely 
hysterical cases my paper has had nothing in compaon, as he can 
inform himself ^/mp/j/ by a reference to its contents. 

Within the last few weeks I have met with three cases* of 
epigastric pulsations, two of them occurred in females, but as 
ray reviewer may believe the masculine gender to beless" Ay«- 
ferica/," as well as otherwise more worthy than tlie feminine, 
I shall introduce to his notice a male subiect. 



* Soch 1 cue bfti been referred to in the original piper* 



Mr. Fausselt's Reply to the MedicoChirKrgical Revieicer. 427 

Cask I. — John Cowser^ aged twenty-eight, (ouglit (o have 
been " thirty," secundum BcnlUe,) the butler of a gentleman 
living near this city, complained of occasional inordinate pulsa- 
tions at the epigastrium, with extreme tenderness on pressure 
there ; slight pressure caused much uneasiness, but an increase of 
it very considerable pain, yet reaUy, and " of course this patient 
had" not " tenderness in every part to which attention was di- 
rected ;" I say, of course, because the patient most obviously did 
not labour under that anomalous form of hysteria, " which apes 
all maladies," but under an unpretending state of visceral con- 
gestion, or over- fulness of the abdominal epigastric vessels, im- 
plicating, most probably, the ganglionic nerves and plexuses, 
at all events deranging the functions of several of the organs 
which those nerves supply. Waving theory however, let tacts 
speak for themselves. With epigastric tenderness, there was 
fulness, a great sense of vital depression, emaciation, loss of 
strength, loss of appetite, headarh, sallow complexion, pallid 
lips, torpid bowels, cold feet, &c. &c., pulse undisturbed. Such 
were tlie leading symptoms. Tlie following was tlie treatment. 
He was twice leeched and then cupped at the epigastrium, 
after which, antimonial ointment was freely rubbed over this 
region ; his bowels were acted upon by mild aperients, and 
then, blue pill combined with henbane and ipecacuanha, as in 
the former cases, was directed to be taken twice daily, until the 
gums became tender, not so as to produce '* scUivatiwi" His 
diet was made to consist of milk and the farinaceous vegeta- 
bles, animal food during the medicinal treatment was abstained 
from, and wine and all stimulants were strictly prohibited. I 
have lately had the gratification to learn, that in about a fort- 
night from the adoption of the above course of treatment, the 
patient^s health became almost entirely renovated. There was 
m this case no indication for general bleeding, and if practised, 
it would have, undoubtedly, proved injurious. Topical bleed- 
ings, however, followed by counter-irritation, were attended with 
decided beneBt. 

Whether such a case as the above, in either male or female, 
should come properly under the denomination of** hysterical,^ 
or whether the result would not in any or in every case, justify 
the view taken of it, as well as the practice put in force, let 
the candid reader decide ; for it is with such cases, and such 
only, that my paper has had any thing to do, and to such, 
that, in any respect, the principles of the treatment applied ; 
all of which my learned, if not too hasty reviewer, might have 
very well conceived from the whole tenor of my descriptions, 
as well as from having expressly disclaimed any allusions to 
cases ** merely hysterical,'^ or to ** those cases of pure nervous 



42d Bibliograhic Noticei. 

debility, clefnanding the use oftoniCSy shother 6alh9f aed gefie- 
tons diet,*^ How Xny reviewer, a rigid dilK^ipte, " according to 
his own shettring" (for which learned expression aee Ja^n^ 
son's Dictiotmry, if not there see Johnson's Review,) of Baillie^ 
and an admirer of Colien, oduld hate setn •* several cases^ 9aA 
as I have described, and yet mistake them for hysteria, 
admits of conjecture. The reader may pardon wich attempts 
to delude Iiim, but Bright, and the shaaes of Ctillen, Hamiltoir, 
Good, and Armstrong, together with the ashes of Sydenham, nrm 
afterwards to be appeased. The two complaints are essentiall j 
distinct, as well as easily distinguishable from each other by the 
exercise of common attention. 

In hysteria there is seldom miich loss of iiedi. In the com- 
plaint, of which epigastric pulsations form bwt a symptom (and 
which, perhaps, ought to be called by the name of epigastric 
chronic congestion,) emaciation is generally considerable. Hy»* 
teria, properlv so called, is almost peculiar to women. Elpigastrie 
congestion, if^the title be allowed, is also to be met with in ineit^ 
yet less frequently in men than Women. Hysteria may occarat 
puberty, the time of its occurrence being generally that of die 
menstrual period. Epigastric congestion has no necessary oon* 
nexion with the menstrual secretion, has not been described aa 
occurring with such a train of symptoms so early as puberty, and 
ctjBteris paribus, is oftener to be met with at the middle periods 
of life than hysteria is. In the one complaint there are alternate fits 
of laughter and crying. In the other no such 8ymi)tom8 are to be 
noticed, lik epigastric congestion i^erei^cXttn epigastric tcnder^^ 
ness differing m diflTerent cases, but always increased by ppessoie* 
In hysteria pains are vaguely, and at random complained of, being 
often as much aggravated by pointing at the site of pain, as by 
pressure. Finally, in epigastric congestion there is no hysteric 
paroxysm, no " clavus hystericus," no " ventris ntunrnaraT 
of Cullen, no *^ sensus globi in abdomine se volventis, ad ven- 
triculum et fauces ascendentis, ibique strangulantis/* no " so^ 
por, convuisiones, urina* limpid^e copia pr^usa, anmm, nee 
sponte, vai-his et mutabiUs.** 

The suffering is of a different kind, and ttie countenance 
betrays it ; there is a steady, earnest, unpretending look of dis- 
tress, a look of absolute, hot fanciful endurance ; add to all 
which that " hysteria is always relieved, often cured by tonics, and 
frequently benefited by stimtUants,''* while epij^astric conges- 
tion may generally be cured by a directly opposite method of 
treatment, and the blood, which in a severe case, it may l>e ne- 
cessary to abstract, will be found both buffed and cupped. 



• Ste Bright'* Medical Ueport^s, vol. ii., part 2. 



Mr. Faussett's Reply to the MkcHco-Cldrtagical Reviewer. ^2S) 

Let iiot my mviewer then again confeund this diaoaae with 
hysteria. Mason Good^ Cullen, and Armstrongs describe the 
latter affection with some accuracy ; I would recommend him 
the works of those authors. Even a hasty redew may add 
correctness to some future critique* JBtt^^ our learned censor 
** has met with cases of this disease, [epigastric congestbnj 
as well as his neighbours^ This classical/ and gratifying as« 
surance imports, no doubt, some corresponding advantage to the 
profession, as well as to mankind at large ; but no I our critic's 
experience, and the results of his treatment, are locked within 
his own breast — ^he is silent upon the subject, at least not par- 
ticularly communicative. *^ For our own parts," says he, '^ we 
endeavour to discover the cause in every case, and having dis- 
covered, to remove it." This, indeed, is philosophical 1 but 
has our reviewer ** in every case" discovered the cause ? or 
has he in any case removed it ? if so, what remedies has h» 
used ? are they essentially different from those which have been 
referred to, (and which of course ought to be - used discri^ 
minately, and modified to the case) ? if they are, I will venture 
io affirm that his remedies have been applied to cases en- 
tirely different from those which Baillie describes, and with 
such only we have to do ; if they are not, and that he se-^ 
lects cases *^ whose symptoms ape all maladies," and applies 
to tliem the treatment in question, then his success will be 
in proportion to his judgment It is to be hoped, however, 
that my reviewer's hastiness to decide does not oharacCeriase 
his practice, as it undoubtedly does his criticisms, else his 
patients and readers will have a common cause of quarrel 
witli him. 

But, to continue: my '^ theory^* has received an especial 
mark of my reviewer's displeasure ; for he thinks my reason- 
ings '* hypothetical and not conclusive.^* He would, however^ 
do well to remember, tliat my reasonings were derived from facts^ 
and not from hypotheses, and that such facts were given merely 
as ^* so many evidences of congestion, or chronic inflammation, 
implicating the ganglionic nerves and plexuses." But, 1 have 
no right to theorise at all, because I have '' discarded spectda-^ 
tion." I must here remind my reviewer, that while I tried to 
distinguish what was theoretical and doubtful, from what was 
practical and known, / did not disclaim for mgrself the right of 
forming a just theory, to account for the phenomena of epigas- 
tric puU»tious, and tlieir accompanying symptoms, as well as 
for the marked and uniform success of a particular method of 
treatment. Jiuty *' Mr. Faussett's theory, is not entertained for 
nothing ; it is the foundation of his practice." My reviewer's 
courtesy is equal to his candour ; else, if he were not in baste 



430 Bibliographic M)tices. 

to censure, he might otherwise interpret plain language, e. g. 
** llie treatment comes easily to be inferred from such a view of 
the subject ; but, the fact is, such a Hew of the svbjecty iny^er^ 
feet as it isy has, in a large measure, been derived from the 
results of treatment,** &c. &c. {Dublin Journal, July, 1837.) 

Upon the whole, my reviewer is out of humour with roe; 
my ** paper is too long," my " theory inflammatory, and" niy 
^< treatment not to be lightly used." However, the 1st of Octo- 
ber was approaching; despatch became necessary; the re* 
viewer^s brain was, no doubt, excited ; his gastric nerves in a 
state of sympathetic irritation, and the whole man disquieted; 
the easterly winds might have had their influence. Yet, ivere 
there no silent and uncomfortable reminiscences about ^' several" 
of those " cases of this affection," which my reviewer had " seen 
as well as his neighbours,** but which, perhaps, his neighbours 
had noticed, and, it may be, treated better than the reviewer. 
Mental association is a quick and wonderful process ; I must, 
therefore, make ** allowances** for the critic, particularly as lie 
recommends that some should be made for me. 

At last, my reviewer will leave me with the reader, and I 
thank him for the appeal. I would thank him still more cor- 
dially, if he had not, by garbling evidence, forestalled judg- 
ment. It is said that a blue pill, followed by the black 
bottle, wrought wonders upon " the mood hypochondriac^ in 
Abemcthy's time. If I might venture to prescribe for my re- 
viewer, 1 would recommend him this remedy ; it may dispel 
the vapours, remove obstructions, sharpen his understanding, 
and soothe his mind. At present, he is scarcely in a capacity to 
digest the subject of epigastric chronic congestion. I heg, there- 
fore, to call the reader's attention to the following : — 

1st. Epigastric pulsations are but links in a morbid chain of 
sympathies, whose proximate cause is in all cases the same ; 
which position follows from two tacts : first, that the symptoms 
differing in degree, in different cases, are always of the same 
class ; second, that the same plan of treatment, modified accord- 
ing to the case, is uniformly attended with the same result. 

2nd. lliere is in every case of epigastric pulsations, an over- 
fulness of the abdominal epigastric vessels, either constituting 
congestion, or attendant on subacute inflammation ; if this were 
not absolutely the case, depletory measures would not be at- 
tended with such good success; local bleeding would not be 
found so specifically useful, the blood abstracted in severe 
cases would not be found buffed and cupped; the sense of vital 
depression would not be diminished, but rather increased, and 
the patient, so far from being strengthened, would be weakened, 
and have all his ailments aggravated. 



JVl r. Faiissett's Reply to i/te Medico- Chirurgical Reviewer. 431 

3rd. Iftke symptoms be all referrible to a common cause» and 
if there be in every ease an over-fulness of the abdominal epi- 
gastric vessels, it is highly probable that such a state of the 
vessels constitutes that cause, inasmuch as a removal of such a 
state of the vessels is immediately followed by a removal of all 
the symptoms. 

4th. If epigastric pulsations be but one of many symptoms 
derived from a fixed cause, which may also be said to consti- 
tute, as it were, the essence* of the complaint, such complaint 
should be designated, not by the name of a single symptom, but 
rather by a name which may be used as the sign or representa- 
tive of the whole class of symptoms. 

5th. As the whole class of symptoms, of which epigastric 
pulsations is one, may be traced up to a state of epigastric 
chronic congestion, or subacute inflammation; and as of these 
two morbid states, epigastric congestion may be considered the 
primary, there can be no impropriety in designating such a class 
of symptoms by such a name, especially when it leads to a ra- 
tional and successful method of treatment. 

The reader, perhaps, will admit, that the above conclusions 
are drawn without any very overstrained process of induction, 
and I should hope that my reviewer, alter the black draught, will 
not still insist upon my reasonings being '* hypothetical and 
non-conclusive;^* if so, his gastric nerves must be in a state of 
** morbid irritation,** and in need, perhaps, of a remedy, to 
which that talented and distinguished writer. Dr. James Johnson, 
of London, attaches especial value, viz. : the nitrate of silver. 
In minute doses, it acts like a charm, and upon our reviewer 
may exercise a somewhat marvellous and homoeopathic eSect, 
tranquillizing the nerves, comforting the stomach, and becalm* 
ing the mind. But he has promised to leave me with the reader. 
I shall, therefore, bid him farewell, and turn with some pleasure 
to the confirmation which my views of this complaint, derive 
from his no less distinguished contemporary, the British and 
Foreign Quarterly, scilicet as follows : — 

'^ This paper refers to a well known disease, or rather sympi- 
tom of disease, which is of^n very distressing and refractory to 
treatment. The author does not profess to add much to what is 
already known of the nature and causes of it ; but his communi- 
cation assumes a form of some importance, from containing what 
he states to be a method of treatment, which has been found 
eminently successful in the many cases in which it has been 
tried. 

<^ We believe Mr. Faussett is correct in attributing many 

* The word essence is here used, simply to denote the essential fmrt. 



4ii2 Bihliograpluc Notices. 

cases of this sort to lliat fruitAii source oToIironic malady, abdo> 
minal plethora." 

I Imve to thank the firitisb and Foreign Quarterly for so 
much ikir play, and am proud to add his testimony, to Itie ei&-> 
tent it goes, in oonfirmatton ofthe correctsiens ofmy opinions. 

With respect to not having ** professed to add mucii to what 
is already known of the nature and ciuses of epigastric pulsa- 
tions/' a friend Ims suggested to me, that '< t(ie views set 
fbrth'^ in my paper of the nature, causes, and mode of causii- 
tion of this complaint, ^ were such as had not been advanced 
^fore." I bold demonstration, however, to be better than 
pretension ; and if, in tracing up this atTeciion to its proper 
source, viz. abdominal congestion ; if in classing it merely as 
one of many symptoms of a determinate complaint, or in slievring 
tlie mode of causation through the agency of tlie ganglionic 
nerves and plexuses, I have given any satisfactory explanation of 
the plienomena in question, the object of my paper baa been 
-fdly attained, praoiked that it lead -to tke adoption of what 
I know to be. an efficacious method oftreaimenl. 

With respect to the part which the ganglionic nerves and 
.plexuses may be supposed to take in the production of epiga»* 
trie pulsations, it is admitted that in the present state of our 
knowledge^ everything connected with nervous agency must be 
more or less problematical. The following, however, is tfae 
line of argument which I have adopted : — 

We find a remarkable interlacement of nerves upon the aorta ; 
is it to be supposed that this curious and complicated arrange- 
ment of nerves is placed exactly there, without design, and ir- 
respective of the function of the great artery, tohoBe coats are 
fderoed, and interwoven with its filaments f Undoubtedly not. 
It is placed there in reference to the function of this vessel, and 
must therefore be considered as accessory, and essential to tlie 
production of its normal, or natural pulsation. 

But this pulsation ceases to be natural, and becomes inordi- 
nate. We are, tftereforey led to contemplate the dwnge, in 
some corresponding change or excitement in tbe nervous ar- 
rangement; this, however, we have no means of detecting — 
^but, it being proved to us Uiat tliere coexists a state of epigastric 
congestion, we naturally infer that it is< tlits state of conges- 
tion which gives rise to tfae change in the character ofthe pulsa- 
tion; and om* inference is conBrmed by the fact, that as soon as 
the congestion is removed, the pulsation ceases. Tliis is the 
*^ inflammatory theory r and I would ask the reader, if there 
be anything in it necessarily chinserioal, (HT rather that is not 
probable in the highest degree ? especially, when he remem- 
oers. that there is a contemporaneous disturbance in the functions 



Mr. Faussetfs Reply to the Medieo-Chirnrgical Reviewer, 433 

of othjer organs, whicli branches from those same ganglia sup* 
ply, and also contemplates the many causes for congestion which 
are to be found in the respective processes which these organs 
carry on through the medium of the circulation. But, I have 
gone a step farther than this, though with more reserve, and 
stated the following opinion, viz., that any organ in this region, 
and in the immediate vicinity of the artery, by becoming con- 
gested, may give rise to a change in the character of the pulsa- 
tion, even without implicating the nervous interlacement in inn 
mediate contact with the vessel ; because if a number of nerves, 
as they arise from, or are connected with the ganglia, become 
engased by such congestion, the disturbance produced in their 
functions will be propagated to the nervous centre, and thence 
to the parts supplied from this source, the coats of the vessel 
amons the number. 

This proposition, I purposely separate from the former, 
as not being substantiated by direct proof, and as better 
suited for a more general inquiry. The importance, however, 
of investigating morbid affections by the lights of physiology and 
anatomy, being fully admitted at the present day, we cannot, 
with justice, be accused of a fondness for speculation, if, in se- 
lecting undoubted anatomical facts, and the well established 
truths of physiology, and comparing these with the results of 
practice, we endeavour honestly to derive from thence fixed and 
certain principles. 

There are minor degrees of pulsations at the epigas* 
trium, not so violent as those that have been referred to, but 
nevertheless inordinate, which often escape notice from not being 
particularly complained of by the patient, and being as it were 
masked by the digestive ailments with which they occur, and 
which appear to occasion greater distress. Does this complaint, 
then, diflkr from what we have been describing? Certainly not. 
There is a difference in its manifestation by its symptoms, but 
the complaint itself is essentially the same, and the practitioner 
who upon inquiry has ascertained the coexistence of minor inor- 
dinate pulsations, with the now more prominent group of diges- 
tive ailments, and looks upon the whole merely as indications of 
a state of epigastric congestion, will diagnose the morbid condi- 
tion w&ich he explores with greater accuracy, and probably treat 
it with better success, tlian he who refers its symptoms to the 
vague and already too general term, dyspepsia. He will also, by 
extricating so many cases from the multitude of those that range 
under such a title, and reducing them to a distinct class, be con- 
tributing to the investing medicine with certainty,* in recog- 
- — I • 

* Though inedicioe can never trriveat absolute certainty, turel; this make* nj 
objection to the nearest approaches to it being sought after. 

VOL. XII. NO. 36. 3 I 



434 Bibliographic Notices » 

nizing necessary distinciiond^ and attaching to names precise 
ideas. 

It might be further shown^ that what has been described 
as congestion, implicating the ganglionic nerves and plexuses, 
and giving rise to inordinate pulsations of the aorta, together 
with dyspepsia, may be also so modified, as to occasion the lat- 
ter, without at all producing the former. For it does not appear 
less likely (making every allowance for difference of structure 
and function) that any given derangement in the centre of those 
nerves should produce corresponding effects, now in one organ, 
now in another, and again in several, than that certain lesions of 
the cerebro-spinal system, should occasion in one man, some loss 
of sensation; in another, some loss of motion; and in a third, 
someloss of both. It might be here interesting to examine how 
many of those phases of disease, or aberrations from a healthy 
state, which come generally under the name of dyspepsia, depend 
upon particular morbid impressions made upon the ganglionic 
nerves and plexuses ; for, as healthy digestion may be thought 
more or less dependent upon the integrity of the functions of 
those nerves, so must unhealthy digestion be supposed to be va- 
riously influenced by their derangement. This subject, how- 
ever, would necessarily embrace many considerations, far be- 
yond the limits of the present inquiry : therefore, to return to 
that which is more immediately before us, I am disposed to 
think that inordinate pulsations at the epis^astrium (at least in a 
minor degree) areoftener to be met witn than is generally ima- 
gined. First, from having recently met with as many as eight differ- 
ent cases, where the patient made no intelligble allumon what- 
ever* to a pulsatory affection at the epigastrium, until concur- 
rent ailments led me to inquire for, and afterwards detect this 
symptom ; and secondly, from noticing (what must be fami- 
liar to every one,) that in the lower ranks of life, patients de- 
scribe their complaints in a manner so obscure, that their mean- 
ing is very apt to be mistaken. Of this, the case of Rossf is an 
illuslration, who called the violent beating of her aorta, '^ a 
working of her stomach" Another will be heard to call it *' a 
sort of terrible fluttering of the stomach /" and others, " an 
impression at the heart,' or else *^ a beating and soreness" of 
this organ. These descriptions, however ludicrous, may yet al- 
low us to conclude, that if inordinate pulsations cannot be sus- 



* The cases above aUuded to were met with in dispensary practice, and it is 
curious how prominent and remarkable circumstances connected with the com- 
paints of the poor will sometimes be entirely omitted by them in recounting thei'' 
ailments, and will be afterwards as if by accident revealed. 

t See Dublin Journal, July, 1837. 



Mr. Faussett's Reply to tlie Medico-Chirurgical Reviewer. 435 

pected from such allusions, and happen not to exist at the mo- 
ment we see the patient, they may escape notice entirely. I 
shall now briefly detail some cases, illustrative of the general 
subject and of the foregoing remarks : 

Case II. — James Dwyer, aet. 35, of rather a plethoric habit, and 
by occupation a gardener, complained of a general decline of health 
for not his wonted ability to labour,hiscountenancewasdepressed, 
had six months back; his strength and health were failing him; he 
his spirits sunken, his bowels constipated, his appetite impaired, 
&c. He complained also of weight and uneasiness at the epi- 
gastrium, where there was considerable fulness, together with 
pain on pressure. These symptoms led me to ask the patient if 
he ever experienced a beating or palpitation in any particular 
place, he immediately answered in the affirmative, and pointed 
Lis finger to the epigastrium as the seat of it : he described it 
as occurring every day at noon, and continuing for about three 
hours, after which it left him, but generally returned with 
severity ** as he lay down at night.** Purging, counter-irritation, 
by means of an antimonial plaster, and mercury, henbane, and 
ipecacuanha, administered daily till the mouth became a little 
tender, brought the patient to a state of convalesence. The 
inordinate pulsations have entirely ceased, and he at present 
feels himself in every respect better than he has been for six 
months previously ; in his own parlance, he has become ^' a new 
man.'* Leeches, though directed in this case, were not applied, 
the consequences of which* were, as I apprehend, that the cure 
was slower in progress, and that the pulsations did not as 
usual cease about the time that the mouth became afiected. 
The bowels, however, were freely acted on after this period for 
two or three alternate mornings by means of aperient medicines, 
and this appears to have completed the cure. In another and 
more severe case of epigastric pulsations where the whole rou- 
tine of treatment referred to was put in force, there was a slight 
return of the aflection, which free but gentle purging in like 
manner completely removed. 

Case III. — Mary Mooney, aged about 30, in the habit 
of working daily in the fields, presented herself, complaining of 
a sense of oppression and uneasiness at the epigastrium, where 
she experienced pain on pressure, her countenance looked 
downcast, and her spirits sunken, she had not enjoyed her 
wonted health and vigour for some time previously, she was 
somewhat reduced in flesh, her bowels were costive, and she had 
in some degree lost her appetite. This patient had been twice 

* It is not to be inferred from this, that the writer holds topical blood-letting to 
be in every case indispensable for effecting a cure, although very generally necesar' 



436 Bibliographic JVatices. 

seen and prescribed fcHr^ with little relief, but upon the third 
casion her case was more carefully entered into, when the well 
known group of symptoms just detailed, became more partica- 
larly recognized, and led also to the detection of palsations at 
the epigastrum. The course of treatment already noticed was 
then put in practice in a manner suited to the case, and tbd 
result was, that the patient quickly and perfectly recovered* 

Case IV. — Charlotte Clare, a small and delicate locddng 
woman, aged 29, was visited November 4th^ and found con- 
fined to her bed. About four months previous to this she got a 
severe beating, the several circumstmices connected with which 
occasioned her much distress and anxiety of mind. She also re- 
ceived a blow at the epigastrium, whereupon she fainted^and we* 
mained, as she states, exceedingly ill for some days aft^*wards; 
occasionally spitting up blood. Slie was at this time pregnant, md 
within the lastfew weeks aborted with considerable hsemorrhaee. 
From the period that she received the beating, however, up teuie 
timeofmy visit,her chief complaint was a sense of weight and con- 
striction at the epigastrium, which she described in a remarkable 
manner, viz. : *^ as if one put his knee in at the pit of the stonach 
and pressed her down against something hard :" this account I 
took to be a little exaggerated, but, nevertheless, conceived tier 
suffering must have been considerable when it came to be thus 
expressed ; and the uneasiness occasioned by even slight pressure 
of the hand was evidently very great. She did not allude to any 
pulsatory affection until the question was pat to her, when ^ 
described herself as being constantly subject to it, and marked 
put the thrill of the artery downwards towards the umbiiieii% 
and upwards to the thorax : she stated that it commenced about a 
month after the receipt of the injury, and had since occurred 
daily, though with intermissions. Being now convinced of the 
jiature of the case, I determined upon trymg a plan of treatment 
applicable to a state of chronic congestion, yet in a manner 
suited to the extreme delicacy of the patient, whose strength 
was necessarily impaired by a recent miscarriage. She was di- 
rected for the ensuing week to remain as quietly as possible, 
and to live chiefly upon milk, gruel, arrow root, and flummery. 
A small quantity of magnesia was eiven her twice a day, after 
which an antimonial plaster was laid over the epigastrium, and 
blue pill with ipecacuanha desired to be taken as in the pre- 
ceding cases, until the gums became tender ; this was, however, 
discontinued upon some slight soreness being complained of in 
the throat and inner part of the cheek. Nine of the pills were 
at this time taken, when it was also found that the ^ense of con- 
striction and weight at the epigastrium had diminished, and the 
inordinate pulsations entirely ceased. 



Mr. Faussett's Reply^ to the Medico-Chirurgical Reviewer. 437 

In this case it was evident, there was a direct lesion of the 
ganglion of the sympathetic from a blow. " I believe/' says 
Dr. Copeland; '^ from an attentive examination of the pheno- 
mena consequent upon such an injury, {scilicet^ a blow upon 
the epigastrium^) that the immediate effect is produced upon 
these ganglia, and is analogous to that occasioned by concus- 
sion of the brain." There was then a direct lesion of the nerves, 
and with this a rupture of some small vessels : what was the 
consequence of sucn lesion ? reaction, and a determination of 
blood to the part. This by degrees subsided into a state of 
chronic congestion, which, at the time I first saw the patient, 
was manifested by a sense of weight, and constriction at the 
epigastrium, and by epigastric pulsations. Now, as to what 
tne exact state of the vessels may be in relation to the nervous 
ganglia, when these phenomena are produced, I do not pre- 
tend to determine: all I venture to say is, that it is a state of 
plethora or overfulness. A^in, as to wherefore they should 
occur in one case and not m all ? — I can only record what 
I have met with. It would appear, however, as if a sudden 
and violent vascular action in wnich the whole vascular system 
might be supposed to particimte, could not produce the pulsatory 
phenomena, while a state or chronic congestion, creepmg on to 
inflammation, so often does. The one may be considered a sa- 
lutary process, though sometimes erring in the means, and thus 
missing of its end, the other is, perhaps, more essentially a mor- 
bid process. In the case that has been detailed, the unaided 
efforts of nature did not accomplish their end, viz. a complete 
restoration to health, and a state of chronic congestion vras the 
consequence. In the cases that are usually recorded, nature has 
had the assistance of medicine ; cupping, leeching, &c. have 
probably been employed, and therefore no such unpleasant se- 
quelae are found to result. These remarks have occurred to m# 
in contemplating this case, future experience may serve to shew 
their fallacy or truth. 

As the results of observations upon several cases are com- 
prised in all that has been already said, it would be needless 
as well as tiring, for the sake of noticing shades of distinction, 
to enter further into detail in a paper like the present The 
development, however, of a certain form of dyspepsia (exhibit- 
ing itself so often in the same manner) is so constantly to be 
met in conjunction with epigastric pulsations, that nothing can 
appear more probable, than that they take their rise from a 
common cause, while the disappearance of both upon the re- 
moval of that cause, entirelv justifies the assumption. In ven- 
turing to assign epigastric chronic congestion, as the proximate 
cause or essence of the complaint, I have adduced tne several 



438 Bibliographic Notices. 

proofs within my reach, it remains for the reader to test the sounds 
ncss of those proofs, and to refute or confirm them by his own 
observation. I cannot, however, conclude those remarks witboat 
stating the satisfaction which I have often of late felt, in bemg 
able to predicate to the patient, with some degree of con- 
fidence, his chances of a speedy recovery, and in no instance as 
yet have I had reason to repent the exhibition of so much cer- 
tainty as to the prognosis. 



Surgical Observations on Tumours, tcith Cases and Opera- 
tions. By John C. Warren, M.D., Professor of Anatomy 
and Surgery in Harward University, and Surgeon of the 
Massachusetts General Hospital. Boston^ 1837. 

We have read with great pleasure the work of Mr. Warren, 
and we congratulate our Trans- Atlantic brethren on the valu- 
able addition which it makes to the medical literature of their 
country. 

The plan of the work we particularly approve of, and the 
* unassuming and candid manner in which it is written, does 
honour to the pupil of Sir Astley Cooper. The work, profess- 
ing to be " Surgical Observations on Tumours," is what it 
professes, not a category of all known tumours, but a descrip- 
tions of those tumours actually seen, or operated upon by the 
author, and this includes a very large class, and were it not 
that he has permitted several Americanisms to creep into his 
otherwise nervous style, we would not scruple to speak of this 
work in terms of the most unqualified praise. 

The arbitrary division of tumours assumed by Mr. Warren 
is grounded upon the tissue in which they are situated. 
Beginning with the tissues of the skin, he then proceeds to the 
cellular membrane ; then to those of the muscular, fibrous, 
osseous, glandular, vascular, and membranous ; lastly, tumours 
composed of diflTerent textures, and not found exclusively in 
any : viz. encysted tumours, and those contained in the cavity of 
the abdomen. 

Amongst the dermoid tumours we find some new names : 
viz. lepoides, from XcTroc, bark, intended to designate that 
scaly crust or bark-like roughness of the skin, most commonly 
observed in the face of aged persons, and which may be mis- 
taken for a wart. The author thus describes true lepoides. 

** A circumscribed crust, which at first appears like a discokwred 



Dr. Warretfs Surgical Observations on Tumours, 439 

specky or a piece of earth. This falls o£F, and is renovated in the 
same form for many successire years. When the crust separates 
spontaneously, it sometimes leaves a new cuticle behind, which 
gradually thickens. In other cases the cutis being expobed, presents 
a spicular surface of unfavourable aspect. This surface throws out an 
ill-conditioned pus, which dries in the form of irregular scales. At 
length, owing to accidental irritation, or a change in the constitution 
from age or other cause, the cutis ulcerates slowly, and forms an 
Incurable sore or cancer of the face. The tendency of this disease is 
to advance very gradually, without much pain, and without con- 
taminating any parts but those in contact with it, so that the patient 
may live a number of years before he is worn out by it." 

The term keloides is also adopted from the classification of 
Aliberty so called from the red, vascular processes extending 
from the tumour^ and giving it the appearance of crabs' claws. 
Mr. W. although adoptmg, still objects to this term, on account 
of the same idea, though not the same appearances, having 
caused the adoption of the term cancer, for a very different 
disease ; and again, because in one kind of affection which must 
be referred to this head, there are no such processes, lliree 
divisions of Keloides are enumerated. 

1st. A white permanent elevation of the skin. 

2nd. The spider-like pimple of the face. 

3rd. The keloides of Alibert. 

Eiloides, (from ccXoi, to coil.) This name is peculiarly well 
applied as indicative of the appearance of thjs tumour ; the 
description given, and the dehneation which accompanies it, 
are peculiarly worthy of attention from their correctness. The 
author of this critique saw two instances of this disease at 
Tangier on the coast of Africa, in the year 1835. Yet as they 
were new to him, and he had not «een any description of them 
amongst the writers on cutaneous diseases, he regarded them at 
the time as curious anomalies produced by accidental circum- 
stances. However, the description now given by Mr. W. is 
confirmative of the existence of this affection as a distinct 
disease, and has given to it ** a local habitation and a name." 
It is thus described : 

• 

'' A true production of the cutis, and continues so throughout 
Its growth, although it may become very large. The first appearance 
of it is an elevation of the skin, similar to that from a bum ; without 
pain, redness, heat, or ulceration, it increases to a great size ; and 
ultimately affects the patient's health. If removed it is reproduced; 
no cause is known, but a scrofulous habit seems to predispose to it." 

The specimen of this disease removed by Mr. W. had the 



440 Bibliographic Notices. 

appearance '^ of a triple coil of inflated intestine^ each rcil 
of inflated intestine^ being four inches long, and growing bj 
a narrow base from the side of the neck. It occurred in 
a negress." This disease has as yet been of too rare an 
occurrence, or too inaccurately observed, to enable us to give 
any very decided opinion on the subject; but yet it is easy 
to distinguish it from the molluscum of Bateman, which is an 
atheromatous disease, proceeding to ulceration before it has 
attained any very great size, and then exuding a white milky 
fluid capable of producing the same disease iu others by con- 
tact, and occurring in many places on the same person. Eiloide^ 
on the contrary, as far as has been observed, is a disease of a 
solitary nature, peculiar in its form, its main charact^iatic 
being the curious snake-like coils which it assumes, appearing 
to consist of a simple thickening of the skin, capable of ariving 
at any size, and scarcely aflecting the health of the patient 
except by its weight ; occurring in all the cases as yet remarked^ 
on the side of the neck ; and from the evidence of Mr. W. it 
appears that the cicatrix remaining after operation, is capable 
of assuming a form and appearance similar to the original 
tumour. Perhaps it might be ]:Jaced with some degree of 
propriety under the head of the elephantiasis tuberculata of 
Alibert. In any case the profession is indebted to Mr. Walren 
for his notice of this disease, as it m^ draw the attention of 
some of our intelligent army or navy surgeons^ on foreign 
service, to its more accurate investigation. 

It would be impossible, in a review of this kind, to notice 
each article separately, we will therefore pass on, touching 
merely on those points which we conceive to possess originality 
in some of the articles. 

Our author speaking of the division of the sphincter ani for 
fissure of the rectum, says : — 

** In cases where the fissure has been in the side of the rectum, 
I have not divided the fissure, but made the iDcisioa towards the os 
coccygis, from its gp^ater facility. The object being to take off the 
tension of the sphincter, and thus give the fissure an opportunity of 
healing, it is not important where the incision is made, provided there 
be a sufficient division of the sphincter.'' 

We would surest at the same time potential cautery to the 
fissure to insure its union. Although we cannot at once coin- 
cide with the practice recommended, as the dressing of two fis* 
cures must be more diflScult.than one, and the facility which 
accrues to the surgeon of cutting towards the os coccygis should 
not for a. moment be entertained, except in circumstances where 
he could not procure a proper assistant 



Dr. Warren's Surgical Observations on Tumours. 441 

In treating on tumours of the fibrous structure^ an interest- 
ing case is detailed : — 

** The patient was a clerk or writer, 18 years old, possessed 
of great muscular power. In the summer of 1834, he undertook to 
raise himself from the ground, while sitting with his lower extremi- 
ties extended ; and this was to be done without using his hands. 
This feat be succeeded in accomplishing. No immediate inconyenieoce 
was recollected. Two or three weeks after this act, he perceived a 
weakness about the knees, and examining found a slight hardness 
along the tendons of the flexor muscles. He continued to move about, 
but found the tumours and lameness regularly increasing. It was 
three months after the effort spoken of before he applied to me. On 
examining him, there was feit along the tendons of the biceps muscles 
in both limbs, a hardness of about four inches in length, and near an 
inch in thickness, principally seated on the inner edge of the tendon, 
and partly on its posterior face. When the muscles were contracted 
by an effort to raise the leg, the patient lying on his face, the tumour 
became of a stony hardness ; when the muscles were relaxed, it was 
less obvious. No distinct uneasiness was caused by compressing 
the part At this period he was unable to walk more than a few 
steps. After considering his case, I told him, it was of a dilicult 
and protracted nature, and .that most patients became tired of the 
treatment necessary in such a case, and applied to bone and sinew 
doctors, which course, if he had any disposition to adopt, he had 
better do it at once, without giving himself or me the trouble of be- 
ginning a treatment, he would probably not carry through. He then 
informed roe, he had already made a trial of the practice mentioned^ 
and found himself growing worse, and being now seriously apprehen- 
sive of being crippled for life, he was ready to submit to the requisite 
treatment. He was then informed, that he must prepare himself 
for a confinement of at least a year, possibly of two years or more. 
He was directed to keep in a horizontal posture on a bed-; the knees 
to be slightly flexed, and supported in this posture, and never to be 
moved excepting passively. Twelve to eighteen leeches every fifth 
day for the first six weeks. Occasionally a purgative. No animal 
food, and the quantity of food limited. I heard no more of him for 
Bve months. He then sent for me, I found him pale and emaciated. 
He hsd severe pains in the bowels, and frequent bleedings ar the 
nose. He had followed the course directed in every particular. I 
expressed my surprise, that he should have undertaken to proceed so 
long a time, without giving me an opportunity of accommoidating the 
treatment to circumstances. He apologised by intimating, that being 
compelled to relinquish his occupation, he was without means of de* 
fraying more than the expenses of subsistence. From this time I 
attended him regularly. I should have mentioned that the tumours 
were sensibly diminished. He was now directed to take a little meat 
twice a day, to drink from four to six ounces of wine, and forty drops 

VOL. XII. NO. 36. 3 k 



4 12 B'tbliographic Notices. 

of tincture of sulphate of quinine every two boars* Whenever the 
abdominal pains were urgent, to take thirty drops of tincture oi 
opinm. Under this management he recruited slowly, and at the end of 
four weeks, the wine gave him beadach, and was discontinued. 
Animal food was continued a month longer, and then seeming to dis- 
agree with him, was omitted. He now resumed the original coarse, 
with the exception of substituting injections for purgatives, and 
sometimes taking a little meat After eight months' confinement be 
was directed to use frictions of a stimulating liniment, and to have 
the limbs bathed twice a day, in hot water and soap. Finding the 
tumour lessening regularly when he had been confined a year, I di- 
rected him to bandage the whole limb ; and to get out of bed onoe a 
day. . This was followed, after two or three week's trial, with a thick- 
ening of the cellular substance between the hamstring muscles ; in 
consequence of which he was put on the bed for a month longer, and 
then advised to get up and walk the room once a day. At the end 
of fifteen months, he was able to walk a quarter of an hour at a time. 
I now urged him to walk out, but his apprehension of reprodocing the 
disease was so strong, that it was some time before this could be 
affected. At last he got out, and increasing his walks very gradu* 
ally, in three months he was able to walk to my house ; and I had the 
satisfaction to find, that the swellings were wholly dispersed. Sinca 
then he has recovered his strength, and is now perfectly well." 

Among the cases of periosteal tumours^ one is remarkable 
from the practice pursued in the operation. 

'' The tumour was on the right side of the face, extending from 
the edge of the lower jaw to the zygomatic arch, having the size and 
nearly the form of a lemon. It had existed a year ; came on without 
any known cause; was colourless, quite hard; not attended with 
much pain, and made a formidable appearance. The patient's health 
was perfectly good." 

Having determined that it was neither exostosis, osteo-sar- 
copia, nor fungus of the antrum, Mr. W. proceeds : that per» 
ceiving the breath to be oflTensive, he examined the mouth, and 
at length discovered a small aperture leading to the lower jaw. 

" Introducing a probe, I struck a rough bone, and was at once 
satisfied of the nature of the case. I made a perpendicular incision 
about three inches long, and laid bare the masseter; after dissecting 
through this muscle, a semicartilaginous substance appeared; the 
knife with difficulty penetrated this, and being forced to some depth, 
did not reah anything of a different character. I then proceeded 
io excise this hard substance; and neglecting the circumference^ 
cut out a mass an inch and a half square^ and an inch thick, from 
its centre. This being removed, a probe was passed, and struck a 
diseased bone. The aperture was then enlarged, a strong forceps in* 
troduced, and with some difficulty a dead piece of the lower jaw was 



Dr. Warren's Surgical Observations on Tumours, 443 

extracted, about two inches long, and comprising the whole mass of 
the lower jaw bone for that extent. The wound healed favourably 
though slowly; the relics of the hard substance gradually disappeared, 
and the patient was discharged in three weeks after the operation. 
The extraordinary thickening in this instance, was caused by the 
effort of nature to supply the deficiency of the dead bone, connect 
together the separated parts of the jaw, and keep up its motions, which 
were never suspended, though much limited. In this case, as well 
as others of periosteal tumour, an extraordinary sensibility exists in 
the thickened periosteum. This symptom was remarked in most of 
the cases mentioned ; and in necrosis, where it has been necessary to 
remove portions of thickened periosteum, to expose a dead bone, the 
patient has always seemed to suffer excessive pain from cutting this 
part." 

Cases are given in which portions of ribs were removed, both 
with the chain saw and cutting forceps, without injury to the 
pleura, well worthy the attention of the practical surgeon. 

Mr. W. mentions one curious preparation, as being in his 
possession. An exostosis of the periosteum of the femur, which 
encircled the bone like a ring, and wliicli when the peri- 
osteum became dry, revolved easily on its shaft. At the same 
time, it appears to have caused absorption, as the cylinder of 
the bone was furrowed beneath it. 

Several operations are described for the removal of the upper 
jaw, for maxillary exostosis, in which cutting forceps were em- 
ployed (in the manner described by Mr. Liston) so far back as 
May, 1831. Then Mr. W. made the first use of this instru- 
ment ; since that period he states that great improvements have 
been made in modifying the instrument by Dr. rlagg, who gave 
some of them the form of a hawk's bill ; one of them is made to 
cut horizontally, another vertically : thus, the two incisions ne- 
cessary for the removal of a portion of the jaw can be made ra- 
pidly, and witli ease. The French instrument, which is made to 
cut at right angles with its shafl, is also mentioned in terms of 
commendation ; and a proposal is made to bring in the aid of 
an additional lever in the construction of a compound forceps, 
which would give a power of surmounting any resistance which 
an osseous tumour could give, and thus supersede the use of the 
saw. Of this idea we most highly approve, and we feel certain 
that every candid person who has seen the difference between 
the operation as performed formerly with chain, bow, spring, 
or Hey's saws, and that of the present day with the cutting for- 
ceps, would most cordially acquiesce in the opinion o? Mr. 
Warren. 

In osteo-sarcoma of the ribs our author speaks fearlessly of 



I 



444 Bibliographic JVotiees. 

their excision along with the tumour, and cites cases in which 
he has performed this operation ; here as well as in many other 
parts of the work, we were pleased at tlie acknowleagment 
which he makes, that the surgeon must be ruled by circom- 
stances at the time of operation, without regard to rules pre- 
viously laid down by himself or others, if he wishes to adopt 
the course which will be most beneficial to his patient ; very 
many of the cases of operation give evidence of this, although 
in all the plan of operation, with the presumed anatomical dira- 
culties, were fully considered before hand ; still the Doctor 
seems seldom to have deliberated long, when his first incisions 
shewed that a change in his original plan would be more bene- 
ficial. One example from many will suffice. The author having 
determined on the removal of an osteosarcomatous tumour of 
the inferior ribs, and the first parts of the operation having be^i 

Performed to discover the connexion of the tumour with the ribs, 
e thus proceeds : — 

** I uncovered a small portion of the ninth and tenth ribs, and 
soon ascertained that the tumour originated Id the ninth, and was 
adherent to tbe seventh, eighth and tenth. The knife was insinaated 
between the tumour and these three ribs, with some caution on ac- 
count of the danger of penetrating the intercostals ; and now tbe 
tumour being separated from these, was perceived connected with 
the ninth only. A question arose whether it was best to divide tbe 
rib first or to take oS the tumour. Ascertaining that by removing 
the tumour, I could save an inch of the rib by dividing it under tbe 
tumour, I cut off tbe tumour with an inch of the cartilage of the rib, 
and then having the morbid origin of the tumour in full yiew, pro- 
ceeded to remove the rib. The intercostals above and below the 
rib were carefully divided with the knife. The intercostal artery, 
vein, and nerve were separated with the pleura. A small director 
was then insinuated between the pleura and bone ; and on tbe di- 
rector the rib was cut with the cutting forceps applied to the edge of 
the rib. The diseased portion was then dissected from the pleura 
and diaphragm, with a portion of the cartilage of the rib. The ex- 
posed diaphragm rose into the aperture of the wound, forming a sort 
of hernia. The hemorrhage was not great.'' 

Contrary to the expectations of Mr. W. there was no 
thickening of the pleura in this case, which had it existed 
would have been a kind of security in separating the rib. This 
case, which was successful, concludes with the following re- 
mark : — 

*' I would not, however, be willing to have it understood that the 
raising of a rib from tbe pleura or diaphragm is a light and easy ope- 
ration. It is one of great danger both in the execution and the con* 



Dr. Warren's Surgical Observations on Tumours. 445 

seqaence, if the pleura retain its healthy state ; but if it be thickened, 
the danger and difficulty is much diminished." 

In the article on glandular tumours^ a description is given 
of an immense tumour extending from the ear to the clavicle, 
And induding in its substance the carotid artery, internal 
jugular vein and par vagum nerve, and extending deeply into 
the parotid space. This tumour was removed by operation, the 
nerves and blood-vessels having been dissected out of it, with 
the exception of the sublingual nerve, which was cut across. 
As far as the operation and its consequences were concerned 
the case terminated successfully, the patient dyin^ some months 
later of ulceration of his throat After perusing this case, 
a question naturally arises in the mind of the reader, was the 
glandular scirrhus removed, ascirrhus enlargement of the parotid 
gland, or only of that small gland usually imbedded in its sub- 
stance ? The term parotid never occurs in the whole descrip- 
tion. Speaking of the hereditary nature of cancer, a point on 
which Mr. W. lays great stress, he says : — 

** The following instances have occurred within my knowledge, to 
a family in this vicinity. The grandfather died of cancer of the lip ; 
the son had a cancer of the breast, and at the age of sixty was ope- 
rated on by my late father, but died of cancer a few years after. Two 
of his sisters had a cancer of the breast, were operated on, and ulti- 
mately died of the disease. A daughter of one of the ladies had a 
cancer of the breast, which I removed at an early period ; she reco- 
vered, but died some years af^er of disease of the utenjs» A daugh; 
of the gentleman has a cancer of the breast. I have reason to be- 
lieve that other members of the family are affected, and conceal the 
existence of the disease.'* 

A very strange instance is related of the eflTect of imagination 
on the physical frame : — 

" Some time since a female presented herself with a serious en- 
largement of the submaxillary gland, which had become troublesome 
and alarming to her. I considered any attempt to dissipate it by medi- 
cine to be vain, and advised its removal by an operation. She would 
not consent, and to gratify her, I directed some applications of consi- 
derable activity to be made to the part, and these she pursued a num- 
ber of weeks without any change. After this she called upon me, and 
with some hesitation begged to know if an application recommended 
to her would in my opinion be safe. This consisted in applying the 
hand of a dead man three times to the part. One of her neighbours 
now lay dead, and she had an opportunity of trying the experiment, if 
nol thought dangerous. At first I was disposed to divert her from it; 
but recollecting the power of the imagination, I gravely assured her 
she might make the trial, without apprehension of serious consequences. 



4'46 Bibliographic Notices, 

A while after she presented herseif once' more, and with a smfliiig 
countenance infomied me she had used this remedy since I saw^ ber, 
and no other, and on examining for the tumour I found it had disap- 
peared." 

In cancer of the uterus, the author gives it as his opinion^ tfa^ 

*' Excision of the os uteri, may he safely and properly done in soma 
cases. The extirpation of the hody of the organ, I cannot recommaiuL 
I have indeed performed it once, but should not do it a<^in. The aize 
of the uterine vessels, their inaccessible situation, the existence of 
circumstances favourable for maintaining haemorrhage, and the injury to 
the peritoneum, are facts which seem to me to place this disease be- 
yond the hope of successful operation.'* 

Passing from thence to the diseases of the male organs of 
generation, the author in more than one passage alludes to the 
constant use of tobacco, as one of the causes of various diseases ; 
ampngst others, it is mentioned as having an injurious influence 
on the spermatic veins, and if not alone causing varicocele, still 
cooperating with other causes in producing it. 

In the early stages of varicocele, " immersion of the scrotum 
in iced water" is recommended, 

** Until a sense of pain is brought on ; and this to be repeated 
three times a day. The scrotum to be kept as cool as possible, and 
always supported by a suspensory bandage." 

Amongst the various modes of treating varicocele, Mr. W. 
states, that he never had been able to prevail on patients to sub- 
mit long enough to the system of compression employed by M. 
Breschet, of Paris, to enable him to judge of its utility. Tliis 
method is exceedingly painful, consisting in compression of the 
veins in a small iron vice, till inflammation and consequent ob- 
literation of the veins is caused. He states, that ligature of the 
artery is often had recourse to in America, and he seems to 
tliink that such practice is not eminently successful. Excision of the 
spermatic veins, he states to have been his ordinary practice, 
and that its results had been favourable. 
. A case of hydrocele, recorded at page 499, proves that the 
author was not fond of mere palliative measures : — 

'* A gentleman affected with hydrocele applied to me under the 
following circumstances. He had been affected for ten years, and 
the fluid had been evacuated only two or three times. He deter- 
mined to make a voyage to England for the purpose of undergoing a 
radical operation. While in England he was so situated as to be un- 
able to go through the operation, and left England fof Bostoa to have 
it effected here. When he arrived, his hydrocele was large enough 



Dr. Warren's Surgical Observations on Tumours, 447 

to hold a quart of water ; too bard to distinguish the testicle, and 
perfectly opaque. The undulation of water could be perceived, he 
had been told that injection was the proper mode of operating, and 
he wished me to practice it, which I therefore did. The fluid of the 
hydrocele being discharged by trochar and canula, near a quart of 
port wine and water was injected without exciting pain. This being 
evacuated, as much port wine, with a quarter part brandy, was used. 
No pain being brought on, a pint and a half of brandy, with two 
drachms of sulphate of zinc, was injected. This caused a little pain, 
and the injection having been thrice practised,. I would not proceed 
further with it, though satisfied that it would not be followed with 
sufficient inflammation. The next day, however, the scrotum swelled, 
and he had a little fever. On the third day the swelling was rapidly 
abating, and so continued the next two days without pain. G)nvinced 
that adhesion would not be effected, and perceiving the great incon- 
venience he would suffer from waiting the result two or three weeks 
longer, I prevailed on him to submit to incision. The operation was 
directly performed by laying open the whole length of the vaginal 
sac. As soon as this was done, a little water issued. The tunica 
vaginalis was in hardness almost cartilaginous. On looking into the 
sac, I saw a most delicate network of lymph filling the space between 
the testicle and tunic. This lymphatic exudation formed large cells, 
containing abundance of water ; with the finger and a probe I broke 
away all this lymph, cleared out the water, and placed a piece of lint 
in contact with the testicle, the full length of the wound. In this 
way the requisite irritation was produced. In seven days the lint 
was drawn away ; and in three weeks from the period of the incision, 
he was perfectly well." 

Three instances are given of air getting into a vein duriog 
operation,' one of which, attended with the most frightful symp- 
toms, (see page 260^) terminated almost immediately fatally, 
notwithstanding the most powerful restoratives and stimulants 
being applied, and even tracheotomy had recourse to as a 
dernier ressorL 

There are many parts of this really valuable work, which want 
of space, rather than want of inclination, prevents us laying be- 
fore our readers, or even touching on m a cursory manner. 
We could have wished that the author had been a little 
more particular in the phraseology which he employed in many 
parts of his book; we give a few examples that his attention 
being directed to the subject, he may be enabled to correct 
them in the next edition ; page 36, " The next time I saw Miss 
B. was last August, when you was consulted ;" p. 108, " A 
few days ago I met him in the street, and had the pleasure of 
hearing that he was perfectly well, and quite rusged and 
strong;" p. 186, " Had agitated him some;" p. 207, " Was found 
to have between twelve and thirteen pounds, &c.;" p. 227> 



448 Bibliographic Notice$^ 

^' With quite a severe constitutional disturbanoe ;" p. 306» 
" She was seized with a bad chill ;" p. 474, " I lately operated 
on a young woman woman who had quite a large polypus," &c. 
We would not remark those trivial matters, which in a reallv 
valuable work are but as '^ specks on the snow wreath," were it 
not that we wish to preserve the English language in its utmost 
purity. Considering the immense extent over which it is 
spoken at present, it is not irrational to imagine that at some 
future period, it may form par excellence the medium of com- 
munication for the whole globe. It is, therefore, if for no other 
reason, important to prevent any incorrectness or misapplicaticm 
oF terms, or even that useless redundance of phraseology, (a 
fault to which many of our American brethren are prone), from 
creeping silently and unremarked into ita scientific works. 

S« L. L. B. 



I 



SCIENTIFIC INTELLIGENCE. 



Second Report of the London Committee of the Briiieh Assoeia^ 
Hon for the Advancement of Science^ on the Motions and Sounds of 
the Heart ; communicated at the meeting at Ldverpooly September, 
1837. — The CommiUee appointed in London to investigate the 
motions and sounds of the heart, have to present to the Assoeiatioti 
a short account of some investigations of the abnormal sounds of the 
heart and arteries, in which they have been recently occupied, and 
which were not comprehended in their former report. 

Before describing these, the committee would remark, that 
although their inquiries have not been specially directed to that 
subject, yet thev have had many opportunities of verifying the 
conclusions on the natuntl sounds, as presented in their report of 
last year ; and these conclusions not having been since shaken by 
any experiment or rational objection, it may be considered as fairly 
established, that the first, or systolic sound of the heart, is essentialfy 
caused by the sudden and forcible tightening of the muscular fibres 
of the ventricles when they contract ; and that the second sound, 
which accompanies the diastole of the ventricles, depends solely on 
the reaction of the arterial columns of blood on the semilunar valves 
at the arterial orifices. It further appears, that the first sound may 
be increased by an additional sound of impulsion against the walls of 
the chest under certain circumstances of posture, of increased action 
of the heart, and of particular stages of the respiratory act. It is 
also obvious, that the character of the first sound may in some 
measure depend on the closure of the auriculo-ventricular valves, 
and on the quantitv of blood, inasmuch as these determine the 
nature and time of tne resistance, against which the muscular fibres 
of the ventricles tighten. So likewise the vigour of the ventricular 
systole, the quantity of blood propelled by it, the sudden and 
complete character of the diastole, tne fulness of the arterial trunks, 
as well as the perfect, mobile, and membranous condition of the 
semilunar valves, will determine the character and loudness of the 
second sound. An experimental illustration of one of those condi- 
tions was observed by tne committee during one of their experiments 
on the ass — a great dimunitioo of the second sound on the carotid 
artery being freely divided. 

VOL. XII. NO. 36. 3 L 



450 Scieiiiljic Intelligence. 

As additional illustrations of the production of a sound like (hat 
of the hearty by muscular contraction, the committee have noticed 
that accompanying the action of the paniculous carnosus of the ass 
during life, and the quivering contraction of muscles immediately 
after death. The sound produced in the latter case, in nature and 
frequency, closely resembled the first sound of the heart of the foetus 
or of small animals. 

In investigating the morbid sounds of the heart, the attention of 
the committee has been chiefly directed to the causes of those re- 
markable and various accompaniments of the heart's action, called 
murmurs, which were happily compared by Laennec with the noises 
of blowing, filing, rasping, sawing, purring, cooing, &c. This inquiry 
consists of two parts : 1. What is the essential physical cause of the 
phenomena in Question f and 2. How does the apparatus of the 
circulation develops this cause in the various instances in which the^ 
phenomena are known to occur ? To the first of these inquiries, 
the experiments of the committee supply what they trust will be 
deemed a satisfactory answer: the second is to be answered by 
extensive clinical and pathological observation, rather than by direct 
experiment ; and although a few physiological experiments will he 

3 noted to this point, yet the committee do not profess at present to 
o more than open this inquiry to all those who have the means of 
pursuing it. 

Experiments on the Production of Sound by the Motion of Water 
through a Tube. — 1. A caoutchouc tube, eighteen inches long, and 
three-eighths of an inch in diameter, was attached to the stop-cock of 
a reservoir, in which there was water to the depth of from eight to 
ten inches. 

When the water flowed perpendicularly through this tube (the 
air being first expelled,* and the lower end of the tube kept under 
water in the recipient below,) no sound was heard ; but on pressing 
any part of the tube, so as to diminish its calibre, a blowing sound 
was heard at and below the point of pressure, and this sound became 
louder and more whizzing as the presure was increased. The 
loudest sounds were obtained at the lowest end of the tube, where 
they were sometimes quite musical ; and by increasing the pressure at 
regular intervals, a periodic increase and raising of the sound was 
produced, which closely resembled the sound heard in the neck, to 
which the French have given the name of " bruit-de-diable." 

2. A pin being stuck transversely through the tube, a slight blowing 
was heard. A similar phenomenon more distinctly resulted from the 
use of a split goose quill placed in the same way. A stronger 
blowing was produced by two threads across the diameter of the 
tube, especially when they were rather loose ; and a still louder and 



* At loDg as any air remaini in the tube, a loud crepitation accompamei the 
current. In most of these experimentB a Beiible ear*tube, without its cone, was 
used, ts being more easily applied than tbt common stethoscope. 



Scientific Intelligoice. 451 

sliriller sound ensued when a knot of string was fastened to the 
threads. 

3. The same tuhe being adapted to the stop-cock of a water 
supply-pipe, through which the current could be let to pass with 
great force, it was found possible to imitate every variety of blowing, 
whizzing, and musical murmurs, by varying the pressure on, or 
obstruction in, the tube, and by altering the force of the current. 
When the current was strong, the least obstruction caused a murmur, 
but with weaker currents, greater obstructions became necessary for 
the same effect. An obstruction, which, with a weak current gave a 
blowing sound, produced with a stronger current a sound of a more 
whizzing character. Grating or rasping sounds were best obtained 
by the effect of a strong current on a knotted thread across the 
diameter of the tube. The musical or uniform sounds resulted 
from a moderately strong current through a considerable impedi- 
ment ; increasing the force of the current or the degree of obstruc- 
tion, rendered them whizzing and imperfect ; diminishing the current 
or the obstruction, converted them into a simple blowing. When a 
sound was of an appreciable pitch, its note was hi^h in proportion to 
the force of the current and the amount of the obstruction, — a fine 
forcible stream producing the highest note. Sometimes, however, 
with a strong current, a loud trumpet note would be set up, which 
was not altered in pitch, but only in force, by changing the strength of 
the current. This kind of note produced visible vibrations of the 
tube below the obstruction, and seemed to have relation to the 
length of the tube. In many instances these vibrations resembled 
closely the purring tremor and thrilling vibration sometimes felt in 
the region of the heart and large arteries. Musical sounds of a more 
variable character, like the cooing of a dove, the humming of an 
insect, or the whistling of wind, were produced with weak currents 
passing through a tube much obstructed. The pressure of a column 
of water only two or three inches high, was sufficient to give acute 
whistling notes, which were sustained, although varying, even when 
the water that passed, only fell in drops from the end of the tube. 

4. Bending the tube to an angle produced a murmur ; but no 
sound' resulted from any curve that did not infringe on the calibre of 
the tube. A circular constriction, by a thread drawn round the 
tube, caused a murmur, which was blowing or whizzing according to 
the strength of the current. 

5. The current issuing from the end of a tube, or from the 
mouth of an India-rubber bottle, produced a blowing sound when it 
impinged directly on an opposite surface, such as the side of the 
recipient or the end of the stethoscope ; but unless the current were 
very strong, this sound was not produced when the current played 
on the surface very obliquely. 

6. When the tube, with a weak current, was pressed on at two 
]>oints, the murmur was heard at the point where the pressure was 
greatest ; and by increasing the pressure at one point, the sound was 
stopped at the other. When the current was strongs it was easy, by 
a pretty equal pressure, to cause a murmur at both points. 



452 Scientj/ic Intelligence, 

7. With a stroDff caoutchouc tube, two feet long, and one inch in 
internal diameter, the same results were observed, but in a more 
remarkable degree, in consec^uence of the increased size of the tube. 
When the current was strong and the pressure on the tube consider- 
able, sounds were produced loud enough to be heard without apply- 
ing the stethoscope to the ear, and the vibrations of the tube below 
the obstructions were so strong, that they threw the water in little 
jets from the outside of the tube. 

8. In making the last experiment, the pressure of the water 
suddenly distended a portion of the tube into a globe about three 
inches in diameter, constituting a good representation of a circum- 
scribed true aneurism. As long as the force of the current was 
sufficient to keep the walls of the dilated portion distended, no 
murmur was produced ; but when these walls became flaccid, the 
passing current caused a kind of dull fremitus in them. Slight 
pressure on the dilatation or bending the tube to form an angle at 
the point, also sometimes occasioned a murmur. 

9. A globular India-rubber bottle, three inches in diameter, 
beinff adapted to an aperture in the side of a tube, so as to form an 
elastic sac communicating with it, and the air being expelled, the 
current of water was directed through the tube. The same was done 
with a smaller tube, and a bottle one inch and a half in diameter. 
In some positions the current, in passing the lateral sac, occasioned 
a slight whizzing ; but in others, as when the tube was straight, there 
was no sound. A sudden increase of current, or the removal of 
pressure from the sac, caused a whizzing, by the entry of water into 
the sac. Independently of the current, sudden forcible pressure on 
the sac occasioned a whizzing with the expulsion of the fluid ; and a 
similar whizzing attended its rapid reflux into the sac on the removal 
of the pressure. 

10. Some of the preceding experiments being repeated with 
water made slightly glutinous with size, it was found that the various 
sounds were not quite so readily produced as with plain water, and 
required a greater force of current. 

From ml these results (1, 2, ^, 4, 5, 6, &c.) it is sufficiently 
plain that a certain resistance or impediment to a liquid current is 
the essential physical cause of all murmurs produced by the motion 
of fluids in elastic tubes. That any condition of the walls of the 
tube beyond the obstructing point is not, as it has been sup- 
posed, essential to the production of these sounds, is proved by 
the fact, that they may be produced by an obstruction at the terminal 
orifice of the tube, or at the mouth of a gum-elastic bottle, where 
there is no tube or wall beyond to cause them (1^ 5); and usually 
this is the situation where they can be produced best, because here 
the current has acquired its greatest momentum, and finds a freer 
passage beyond the obstructed point. The more flaccid state 
of the portion of a tube beyond an obstruction, is a necessary 
effect of the impediment caused by that obstruction to the passage 
of water. It is therefore a necessary concomitant of the obstruc- 
tion, but it is not the cause of the sound. When, however, the 



Scientific Intelliffence. 453 

sound oecasioned by the obstruction is strong its vibrations may 
be communicated to the whole contents and walls of the tube 
beyond (3, 7,) which will then vibrate in system with it, and be 
capable of modifying its note ; just as the tube of a reed instru- 
ment aff^ects the note, which is generated exclusively in the reed. 
On the other hand, when the sound is weak and varying, the con- 
dition of the tube or walls beyond it will not affect it. In short, the 
laws of the production of sound by liquids, so closely resemble those 
which regulate the same phenomena m air, that it is unnecessary to 
enter into further detail respecting them. It may be necessary to 
advert to an objection to tnis view, that a murmur is sometimes 
caused where there is no impediment to the course of a liquid, as 
when it passes suddenly from a small into a large tube or into a sac. 
In the first place, it is not quite correct to assume that in this case 
there is no impediment ; for the liquid in the large tube or sac 
haviuff less velocity than that in the small one, must itself be an 
impediment. But besides this, the course of the small swift current 
becomes changed by spreading into the larger channel, and instead 
of running smoothly parallel to the tube, now strikes its walls at an 
ande, causing a series of impulses and resistances which, if forcible 
and rapid enough, constitute the vibrations of sound. It is in the 
same way that a current produces a sound by impinging against an 
opposed surface (5.) It may be observed, however, that these in- 
direct kinds of impediment to a moving current, are not so constantly 
attended with the production of sound, as the dire^ obstacle pre* 
sented by a narrowing of, or projection into, the calibre of the tube. 

Experiments on the Production of Murmurs in the living 
Body* — 11. About two inches length of the common carotid artery 
of a young donkey was laid bare.. Different degres of pressure, 
either by the stethoscope, or by a probe pushed under the artery, 
occasioned a variety of murmurs, blowing, sawing, filing, and 
musical or cooing at each pulse. When the stethoscope was merely 
placed in contact without pressure, no murmur was heard, but only 
a simple impulse and sound, which was distinct only when the heart 
acted strongly. 

12. The artery was scratched for a few seconds with the point of; 
a scalpel ; it gradually became sensibly smaller for the length of half 
an inch about that poiut. A strong solution of salt being applied, 
the contraction increased ; but it was still of a gradual and tapering 
kind, and the stethoscope could not detect any murmur in it ; very 
slight pressure was enough to cause a whizzing. The pulse at this 
contracted portion was felt to be much harder and sharper than 
above or below it. 

13. A small incision being made into the artery, a jet of blood 
issued, and a whizzing,^ sometimes continuous liKe the bruit- de- 
diable, sometimes only in pulses, was heard beyond the orifice, but 
no sound on that side of the orifice nearest the heart ; the sound 
being, as usuaU carried in the direction of the current. The incision 
being made larger, the blood spouted out with whizzing to the dis- 
tance of more than six feet, and the animal died in the course often 



454 Scientific Intelligence. 

minutes. After this last incision the beats of the heart were frequent, 
short, and pretty loud, but without a second sound, and without any 
murmur to the last. They continued for nearly two minutes after 
the respiration and consciousness had ceased, becoming gradually 
slower. 

14. The Committee repeated the observation that has often been 
made before, that a murmur can easily be produced by pressure on 
the subclayian, carotid, or femoral artery of the human subject. 
This murmur is generally of a grating or filing character, and is pro- 
longed in proportion to the degree of pressure. 

15. Whilst making the observations on the carotid, they found 
that a continuous murmur of very remarkable and variable characters 
could be produced by pressure on the jugular veins. The most com- 
mon sound thus produced was like the humming of a gnat or flv, 
but occasionally it resembled the whistling of wind, the singing of a 
kettle, the cooing of a dove, and sometimes it was perfectly the re- 
mittent whirring noise, which the French have called the bruit-de- 
diable. Dr. Ogier Ward, of Bermingham, had previously come to 
the conclusion Uiat this sound is produced in the jugular veins ; and 
the observations of the Co